Recurring concern

Unreliable ambulance-service computer systems for safety-critical information

First to latest report 30 Oct 2013 — 27 Jan 2020

Reports that mention this concern
6
Times this concern has been raised
6
Stated actions linked to this concern
8

What this concern includes

Includes failures of ambulance-service computer programmes and integrated call-handling systems that fail to account for, synchronise, update, display or otherwise make safety-critical clinical or operational information available for emergency response decisions.

What is not included
  • Excludes failures of ambulance dispatch capacity, call triage or clinical judgement where no computer-system deficiency is identified.
  • Excludes generic electronic patient-record or hospital information-system failures not specifically tied to ambulance-service computer systems.
  • Excludes failures limited to transferring information between ambulance services or between ambulance crews and other organisations when the ambulance computer system itself is not deficient.
  • Excludes generic IT access, staffing, training or communication deficiencies unless they directly impair the safety-critical operation of an ambulance-service computer system.

Reports and published responses 6 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Inner North London

    AI-generated summary

    Shanté Andrée Marie TURAY-THOMAS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Shanté Andrée Marie Turay-Thomas ate hazelnuts on 18 September 2018 and died soon afterwards from acute anaphylaxis. The report identifies concerns about inadequate allergy care, advice and training concerning adrenaline auto-injectors, prescribing and clinical communication, and errors in the NHS 111 response and ambulance categorisation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of the Adastra system to update location information across screens in real time

    Wider context from the report

    “14. When Shanté became ill following the ingestion of nuts, her mother rang NHS 111 and got through to the London Central & West (LCW) service. However, the call handler incorrectly recorded Shanté’s location: he failed to untick a box and so her grandmother’s address was recorded as her location, rather than her mother’s address where she was staying at the time. In an example of good practice, this error was recognised by the clinician who later took over the call. However, what nobody at LCW realised was that the Adastra computer system would not then update in real time for any screens save that of the particular clinician inputting the information. The staff at LCW have since been made aware of this and have been trained to walk over and look at the primary screen to check the address, but it is not clear to me that there is now a national understanding of that element of the system. ”

    Source location

    Shanté Andrée Marie TURAY-THOMAS · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deploy a software update warning users when a second user opens the same case and address details may be out of date.

    Verbatim wording from the response

    “This is the first time Advanced has been made aware of the scenario outlined in this case. This involved a second user being asked verbally by the call handler to contact the ambulance service and details from a different screen (that was not the screen in live use) were used. Within two-working days of being made aware of the scenario outlined in this case, Advanced issued a reminder to all call handlers not to manually circumvent the software process and this was followed by a software update being released to prevent this manual override re-occurring ie a message is displayed if a second user opens the same user case, warning them that the address details may be out of date. This was deployed to all customers.”

    Source location

    2020-0124-Response-from-Advanced_Redacted.pdf
    Page 2 · response
    Published 13 August 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Save consultation address changes immediately so they are contemporaneously available to other users on other screens.

    Verbatim wording from the response

    “Subsequently, and as a direct result of this case, we are currently making two changes to the Adastra application which are in development. These changes will ensure that the user will have to actively select, and tick, the address field that is required when there are differences between the locally recorded home address and the PDS registered home address. Also if any changes are made to the address during the course of the consultation they will be saved to the database immediately and will then be available contemporaneously to any other user, on any other screen. We anticipate these changes will be available to all Adastra customers by the end of April 2020.”

    Source location

    2020-0124-Response-from-Advanced_Redacted.pdf
    Page 2 · response
    Published 13 August 2020

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Matters of concern 1–14 and 20 do not concern NHS Pathways and fall outside its remit.

    Verbatim wording from the response

    “HM Coroner raised matters of concern numbered 1 - 20 in the PFD report. Matters of concern 1 – 14 and 20 are not applicable to NHS Pathways. We set out below our response to matters of concern 15 to 19.”

    Source location

    2020-0124-Response-from-NHS-Digital_Redacted-1.pdf
    Page 1 · response
    Published 13 August 2020

    Open published response

  2. Suffolk

    AI-generated summary

    Oliver Hall · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Oliver Hall, a six-year-old boy, became acutely unwell on 23 October 2017 and died in the early hours of 24 October 2017 after developing meningococcal septicaemia. The report identified concerns about NHS 111 disposition information not being transferred to ambulance and treating clinicians, delays in ambulance availability information, and conflicting guidance about the significance of his heart rate.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to transfer the NHS 111 Service’s original disposition information to ambulance crews and treating clinicians

    Wider context from the report

    “1. It is apparent that there is a failure in the process of the transfer information regarding a patient's original disposition by the NHS 111 Service to the ambulance service and the treating clinicians on the ground. In Oliver’s case a non-clinician NHS Pathway Advisor using the NHS Pathway algorithms identified a ‘severe illness and a rash suggestive of septicaemia’ following a 5-minute phone call with his mother. As identified at inquest meningococcal septicaemia was Oliver’s actual cause of death and the NHS 111 Service identified this as a possible risk at 13.00, some 5 hours 45 minutes before it was diagnosed by a medical clinician. In response to their algorithms the NHS 111 Service implemented a disposition of ‘emergency ambulance response for septicaemia’ and an automatic referral was made to the 999 service. This disposition and a ‘severe illness and a rash suggestive of septicaemia’ were included in the information transferred to the East of England Ambulance Service. However, it was then identified that the current East of England Ambulance Service system does not provide the ambulance crew (and therefore in this case subsequently the GP’s) with that information. The message made available to the crew simply read ‘headache/abdo-pain/fever- no access issues, patient not alone 38.8’. Both the ambulance crew and GP’s stated in their evidence that had they known the original disposition from the NHS 111 Service had been suggestive of septicaemia it would have informed their decision-making processes and may have changed their clinical management of Oliver. ”

    Source location

    Oliver Hall · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Consult other ambulance trusts to share best practices and solutions for recording and transmitting patient disposition information.

    Verbatim wording from the response

    “The Trust is currently in consultation with our colleagues in other UK Ambulance Trusts who use the same Computer Aided Dispatch system, some of which also use the same triage system (Pathways) as UK 111 providers.”

    Source location

    2019-0198-Response-by-East-of-England-Ambulance-Service-NHS-Trust
    Page 1 · response
    Published 23 August 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Draft and issue dispatch instructions specifying pertinent information, including NHS 111 disposition descriptions, for transmission to attending resources.

    Verbatim wording from the response

    “Whilst this work is ongoing the Trust is drafting an instruction, which will be issued to all Dispatch staff, outlining the pertinent information that needs to be passed to attending resources. This will include for 111 calls the disposition description as determined by Pathways.”

    Source location

    2019-0198-Response-by-East-of-England-Ambulance-Service-NHS-Trust
    Page 1 · response
    Published 23 August 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The organisation is not constituted to mandate or instruct individual ambulance services on local information-sharing processes.

    Verbatim wording from the response

    “To clarify, AACE is a private company owned by the English Ambulance NHS Trusts. It exists to provide ambulance services with a central organisation that supports, coordinates and implements nationally agreed policy. Our primary focus is the ongoing development of the English ambulance services and the improvement of patient care. We are a company owned by NHS organisations and possess the intellectual property rights of the JRCALC UK ambulance service clinical practice guidelines. AACE is not constituted to mandate or instruct ambulance service wherever we do have national influence via the regular meetings of ambulance Chief Executives and Trust Chairs along with a network of national specialist sub-groups.”

    Source location

    2019-0198-response-by-Association-of-Ambulance-Chief-Executives
    Page 1 · response
    Published 23 August 2019

    Open published response

  3. Leicester City and South Leicestershire

    AI-generated summary

    Graham George Smith · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Graham George Smith died in a house fire at his home on 24 April 2018, after deteriorating during alcohol and benzodiazepine withdrawal and refusing hospital transport on three occasions. The report raised concerns that emergency call handling could not link repeat calls about the same patient and address, and that attending ambulance crews lacked information, senior review and warning of heightened concern.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a system for using linked repeat-call information to provide patient safety-netting

    Wider context from the report

    “It became apparent during the course of the inquest that the emergency call handling system did not have the capacity to link repeat calls regarding the same patient at the same address within a short period of time. As the system is unable to currently link such patterns of call behavior, there is no system in place regarding how this information could be used for the benefit of patients and to introduce safety-netting. There was no senior review or “red flag” warning of heightened concern to alert the attending crews. The court was advised that if the history of recent calls had been known, this may have altered the way in which the attendance was managed. It is acknowledged that any system to capture repeat calls will need to have careful consideration of multiple occupancy buildings and the need for confidentiality, but there may be good working models already achieving this aim, or parallels may be considered with sudden frequent attendances of patients to ED. ”

    Source location

    Graham George Smith · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing CAT access to prior attendances, summary care records and local GP records enables informed onward-referral or safe-at-home decisions.

    Verbatim wording from the response

    “The CAT team has had access to all previous calls and attendances for the past three months. The team also has access to summary care records (which are an electronic record of important patient information, created from GP medical records) and in Leicester, read-only access to SystmOne (a centrally hosted clinical computer system used by GPs and other healthcare professionals in the UK). This enables the CAT clinician to be fully informed of the patient’s past medical history and any care plans which may be in place, enabling them to make an informed decision as to whether the patient requires onward referral or whether the patient can safely be left at home.”

    Source location

    2019-0167-Response-by-East-Midlands-Ambulance-Service-NHS-Trust
    Page 3 · response
    Published 2 August 2019

    Open published response

  4. Manchester South

    AI-generated summary

    Christopher Philip Fields · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Christopher Philip Fields was attacked twice at his home on 12 December 2014 and sustained fatal head injuries during the second attack. Concerns included police leaving before the ambulance arrived and leaving him in the care of another intoxicated person, a substantial delay in the ambulance response, and ambulance call-coding algorithms that may not have identified the need for a Red response.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of ambulance call-coding algorithms to generate an appropriate Red response for critically injured patients

    Wider context from the report

    “3. The fact that the call taker coded the call properly and yet this case involved a patient who was clearly critically injured and despite that fact still did not generate a Red response, suggests that the algorithms used for coding are not accurate and not fit for purpose. In my view this is an extremely serious flaw and may/will lead to future deaths occurring unless it is remedied. (NWAS, SECRETARY OF STATE and NHS ENGLAND) ”

    Source location

    Christopher Philip Fields · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Lead a complete review of ambulance coding systems, incorporating previous call outcomes and Coroners’ concerns.

    Verbatim wording from the response

    “NHS England is currently leading a complete review of ambulance coding systems and trialling a new system. This review will take into account both the”

    Source location

    2016-0194-Response-by-NHS-England
    Page 1 · response
    Published 18 May 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Trial a new ambulance coding system.

    Verbatim wording from the response

    “NHS England is currently leading a complete review of ambulance coding systems and trialling a new system. This review will take into account both the”

    Source location

    2016-0194-Response-by-NHS-England
    Page 1 · response
    Published 18 May 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The AMPDS system correctly coded the incident as Green 2; available evidence indicated the patient was initially conscious, breathing and not time-critical.

    Verbatim wording from the response

    “In regards to AMPDS system, I confirm that based on the priority symptoms given during the 999 call, the system correctly coded the incident as a Green 2. It should be noted that if the patient’s chest had been ‘concealed in’ this would have directly affected his respiratory system and been captured during the breathing algorithm question, resulting in a higher response. I note that the attending police officers evidence supported that the patient was breathing, conscious and able to walk, when they attended the scene, shortly after the first call which supports that the patient’s condition, at that time was not time critical, requiring an 8 minute response (life sustaining treatment). Furthermore this assertion was reinforced by ████████ Pathologist report which supported that the critical injury was sustained during the second assault.”

    Source location

    2016-0194-Response-by-North-West-Ambulance-Service
    Page 2 · response
    Published 18 May 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The ambulance-call coding algorithms are not considered inaccurate or unfit for purpose based on the available case evidence.

    Verbatim wording from the response

    “I therefore do not consider that the algorithms used for coding are inaccurate or unfit for purpose based on the evidence of this case.”

    Source location

    2016-0194-Response-by-Department-of-Health
    Page 2 · response
    Published 18 May 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Concerns about AMPDS design should be directed to its private producer, Priority Dispatch Corporation UK Limited.

    Verbatim wording from the response

    “However, please note that AMPDS is produced by the Priority Dispatch Corporation, a private company. If you have concerns about the design of the product you may wish to contact them direct at the following address:”

    Source location

    2016-0194-Response-by-Department-of-Health
    Page 2 · response
    Published 18 May 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The ambulance coding system is generally fit for purpose; inaccuracies can arise from caller information and staff interpretation.

    Verbatim wording from the response

    “I note the response from North West Ambulance Service (NWAS), letter dated 10 June 2016, confirming that the initial ambulance call was correctly coded as Green 2 because the deceased was conscious, breathing and able to walk at that time. It appears from the limited material in my possession to have been the second assault that inflicted critical injuries and proved fatal, as indicated by the Pathologist’s report.”

    Source location

    2016-0194-Response-by-NHS-England
    Page 1 · response
    Published 18 May 2016

    Open published response

  5. Inner North London

    AI-generated summary

    Adil HABIB · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Adil Habib died at HMP Pentonville after swallowing a package containing crack cocaine during a search while subject to control and restraint; he choked on it. The inquest recorded the death as accidental, with acute respiratory failure due to mechanical obstruction of the upper airway by a foreign object. A concern was raised that the 999 caller did not immediately provide the prison gate location for attending paramedics, and that ambulance call-handling systems did not then show alternative gates for all London prisons.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unavailability of alternative prison-gate information in LAS call-handler systems for other London prisons

    Wider context from the report

    “When a prison officer at HMP Pentonville rang 999 to ask that paramedics attend the prison, the caller did not immediately offer the location of the prison gate that London Ambulance Service should attend. Whilst there is of course an issue for the prison in terms of offering the information, it would be helpful for LAS call handlers to be provided with a drop down menu showing the alternative gates when they input the prison details. I understand that the LAS computer system has been augmented in this respect since Mr Habib’s death for HMP Pentonville, but not for the other London prisons. Perhaps that would be a useful exercise? ”

    Source location

    Adil HABIB · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Add HMP Pentonville’s additional prison gate to the emergency gazetteer with accurate GPS information for satellite navigation.

    Verbatim wording from the response

    “The evidence submitted to the Court during the inquest outlined the actions the London Ambulance Service NHS Trust (LAS) had taken since the death of Mr Habib to ensure that we attend the correct prison gate at HMP Pentonville. At the time of the 999 call to attend Mr. Habib, the Gazetteer in the Emergency Operations Centre (EOC) only held the main postal address in Caledonian Road for HMP Pentonville and the prison officer making the 999 call did not volunteer that a different prison gate was to be used. After being advised that a second gate was operated in Roman Way the address was added to the Gazetteer with accurate GPS information so that when selected, ambulance staff would be guided to the address by satellite navigation.”

    Source location

    2015-0380-Response-by-London-Ambulance-Service-NHS-Trust
    Page 1 · response
    Published 16 September 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Obtain postal addresses for prisons and young offender institutions to identify additional or temporary ambulance access gates.

    Verbatim wording from the response

    “With the assistance of the National Offender Management Service (NOMS) we have obtained a list of postal addresses for all prisons and young offender institutions in the UK and have been assured that the Local Safer Custody Leads have been asked to contact their respective local Ambulance Service Trusts to advise if there are additional or temporary gates to be used, either on a temporary or longer term basis, to those held by NOMS. We have made contact with the Safer Custody Lead for Greater London and established that aside from HMP Pentonville the thirteen prison and young offender institutions operate with a single vehicle access gate.”

    Source location

    2015-0380-Response-by-London-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 16 September 2015

    Open published response

  6. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Winston Llewellyn Johns · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Winston Llewellyn Johns was found unrousable with a blood sugar level of 1.4 during a 999 call. He was advised to undergo CPR, sustained a sternum fracture and multiple rib fractures, and later died in hospital from pneumonia caused by those fractures. The concerns were that the low blood sugar information was not factored into the advice and that the ambulance service’s computer programme contributed to CPR being incorrectly advised.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of the ambulance service computer programme to take account of critical clinical information

    Wider context from the report

    “(2) The computer programme used by the ambulance service does not take into account critical clinical information as a result the operator incorrectly advised CPR despite the risks that entails. ”

    Source location

    Winston Llewellyn Johns · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026