Recurring concern

Failure of emergency response leadership and coordination

First to latest report 7 Feb 2014 — 26 Aug 2025

Reports that mention this concern
16
Times this concern has been raised
22
Stated actions linked to this concern
35

What this concern includes

Includes failures of leadership, command, role clarity or team coordination within an explicitly identified emergency or life-threatening emergency response.

What is not included
  • Excludes leadership or governance deficiencies unrelated to an emergency response.
  • Excludes generic training, staffing or communication deficiencies unless the report directly ties them to leadership or coordination of the emergency response.
  • Excludes failures specific to a separate operational process, hazard or non-emergency incident-management system.

Reports and published responses 16 reports

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

  1. South Yorkshire (Eastern)

    AI-generated summary

    Steven Jones · 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

    Steven Jones, aged 27, was a non-verbal resident of a care home who became ill with sickness, diarrhoea, loss of appetite and sleep disturbance before dying on 10 December 2013. He was diagnosed with a perforated colon, leading to multi-organ failure and hypoxic brain injury. Concerns included failures to escalate carers’ concerns, insufficient incident reporting, delayed medical referral, and delays in calling emergency services and transferring him to hospital.

    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 staff to call emergency services for serious incidents

    Wider context from the report

    “(4) On the occasion of a serious incident of faecal vomit, staff did not assume responsibility for calling emergency services but telephoned the registered managers who in turn did not appreciate the seriousness of the situation resulting in a delay in transferring the resident to hospital. ”

    Source location

    Steven Jones · 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

    Use the Anticipatory HealthCare Calendar to assess health symptoms, direct staff responses, record significant communications, train staff, and audit use weekly.

    Verbatim wording from the response

    “In June 2014 the Anticipatory HealthCare Calendar (AHCC) was introduced. ████████ raised the introduction of this system in her evidence to the Inquest on 9 November 2017. This is a NHS proforma that acts as a criteria-referenced monitoring system for health-related issues in those with learning disabilities. Specific symptoms are listed and given a risk level of Green, Amber or Red; amber and red directly link to required specific staff actions and responses, which are described within the tool and recorded on a Significant Communication Sheet, part of the tool. These range from continued monitoring, through administering pain relief or attending a GP surgery when possible, to contacting emergency services immediately. AHCC is a career-level tool that is directive in terms of response to specific symptoms.”

    Source location

    2017-0357-Response-by-Beech-Cliffe-Limited
    Page 3 · response
    Published 11 February 2018

    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

    Staff were trained and authorised to contact doctors or emergency services directly, rather than being required to route medical issues through managers.

    Verbatim wording from the response

    “All staff had full first aid training, which includes advising them to call an ambulance in an emergency. Sarah gave evidence to the Inquest on 9 November 2017 that all staff have responsibility to meet the needs of residents and all have authority to contact Doctors etc and all telephone numbers are and were kept in a directory in the staff office; there was no need to go up the ladder for approval before the call could be made.”

    Source location

    2017-0357-Response-by-Beech-Cliffe-Limited
    Page 4 · response
    Published 11 February 2018

    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 evidence did not establish that staff encountered or recognised a faecal-vomit emergency requiring an immediate ambulance call.

    Verbatim wording from the response

    “On 7 November 2017 the Inquest heard evidence from ████████ (N'e Hayward) that she was the Senior on duty ███████ told the Inquest that on the morning of 8 December 2013 Clare Gray reported to her that Steven had vomited faeces. Kelly explained to the Inquest that she made sure that Steven was ok and contacted ███████ to relay what had happened. ███████ gave evidence that she could not say for sure if Steven had vomited faeces or if he had passed a bowel motion and then eaten it; the latter had happened previously. The Coroner did not explore this further.”

    Source location

    2017-0357-Response-by-Beech-Cliffe-Limited
    Page 5 · response
    Published 11 February 2018

    Open published response

  2. Inner North London

    AI-generated summary

    William DAVIES · 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

    William Davies was found unresponsive in his cell at HMP Pentonville and died from natural causes, identified as coronary artery atherosclerosis. Concerns were raised about unclear procedures and delays in requesting an ambulance after a life-threatening call, as well as uncertainty among prison healthcare staff about responsibilities and verification of death.

    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

    Unclear process for attending prisoners with life-threatening conditions

    Wider context from the report

    “There seems to be confusion in the prison regarding the requesting of an ambulance after a level one (i.e. regarding a potentially life threatening situation) call has been made by a prison officer. The whole process of attending a prisoner with a life threatening condition seemed unclear to the prison general practitioner (now GP lead) giving evidence. She assumed that a prison officer had responsibility for calling an ambulance, but she was not sure. The GP also did not know that she was allowed to verify the fact of death, and told me that, as a consequence, she carried on with CPR after she knew that Mr Davies had died. And if the GP lead has not got a good understanding of the procedures in place, then other GPs in the prison may not have either. This could prove fatal, depending upon the circumstances. ”

    Source location

    William DAVIES · 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

    Deliver and disseminate an emergency healthcare response publicity campaign to operational, non-operational and healthcare staff.

    Verbatim wording from the response

    “• A publicity campaign (based on PSI 2013/03 Emergency Response Codes) has taken place reminding staff of who can call a medical emergency, who calls the ambulance, the use of the correct medical emergency codes, and what information they should be communicating with the control room (See Appendix 3 – Emergency Healthcare Response). This document was jointly developed with prison service colleagues prior to us taking over healthcare services in HMP Pentonville and our Health in Justice team are reviewing this as part of a wider piece of work around emergency care, including training of staff and standardisation of the emergency bags.”

    Source location

    Response from Care UK
    Page 1 · response
    Published 5 November 2014

    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

    Review emergency care arrangements, including staff training and standardisation of emergency bags.

    Verbatim wording from the response

    “• A publicity campaign (based on PSI 2013/03 Emergency Response Codes) has taken place reminding staff of who can call a medical emergency, who calls the ambulance, the use of the correct medical emergency codes, and what information they should be communicating with the control room (See Appendix 3 – Emergency Healthcare Response). This document was jointly developed with prison service colleagues prior to us taking over healthcare services in HMP Pentonville and our Health in Justice team are reviewing this as part of a wider piece of work around emergency care, including training of staff and standardisation of the emergency bags.”

    Source location

    Response from Care UK
    Page 1 · response
    Published 5 November 2014

    Open published response

  3. Manchester South

    AI-generated summary

    MARJORIE PHILLIPS · 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

    Marjorie Phillips, aged 82, fell from a hoist while being transferred from her bed to a wheelchair and landed on its metal supporting legs. She died several days later from resultant pneumonia. Concerns included possible sling design issues, lifting her with only one staff member present, inadequate adherence to hoist training, and unclear arrangements for calling emergency services, which delayed her transfer to hospital.

    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 clear guidance on calling emergency services and decision-making authority

    Wider context from the report

    “When a very serious untoward incident had occurred and Mrs Phillips had fallen and was in obvious severe pain, there was no clear guidance as to how the emergency services should be called and by whom that decision could be taken. This resulted in her not being taken to hospital as quickly as should have been the case.(FOR FAVERSHAM NURSING HOME) ”

    Source location

    MARJORIE PHILLIPS · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Manchester South

    AI-generated summary

    Edna Smither · 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

    Edna Smither choked on sausage while being fed lunch at Peel Moat Care Home on 25 April 2013 and died later that day in hospital. Concerns included limited up-to-date first-aid certification, a delay caused by a locked door, panic and a lack of calm leadership or training, and failures to report incidents under RIDDOR without delay.

    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 training for calm leadership during emergencies

    Wider context from the report

    “3. All the staff in attendance, by their own admission, were in a state of panic. No-one, including the senior staff took a position of calm leadership and there seemed to be no training for this nor a recognition as to who really was in charge. ”

    Source location

    Edna Smither · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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 designate clear emergency leadership

    Wider context from the report

    “3. All the staff in attendance, by their own admission, were in a state of panic. No-one, including the senior staff took a position of calm leadership and there seemed to be no training for this nor a recognition as to who really was in charge. ”

    Source location

    Edna Smither · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Portsmouth and South East Hampshire

    AI-generated summary

    Marco Antonio Lima De Araujo · 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

    Marco Antonio Lima De Araujo entered the sea near the Round Tower in Portsmouth on 26 July 2012 to assist in rescuing two children and was not seen alive again. His body was recovered from Portsmouth Dockyard on 8 August 2012; the inquest concluded that he died in an accident, with drowning as the medical cause. A concern was raised that there was no formal protocol for reporting and coordinating rescue in life-threatening incidents in Portsmouth Harbour.

    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 formal protocol for reporting and co-ordinating rescue in relation to life-threatening incidents in Portsmouth Harbour

    Wider context from the report

    “I was told at the Inquest hearing that there is no formal protocol for reporting and co-ordinating rescue in relation to life threatening incidents in Portsmouth Harbour. ”

    Source location

    Marco Antonio Lima De Araujo · Prevention of Future Deaths report
    Page 1 · 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

    Formal protocols exist for alerting HM Coastguard to life-threatening incidents involving persons on land or at sea.

    Verbatim wording from the response

    “The formal protocols, for persons on land, for the alerting of HM Coastguard are by calling 999 and ask for coastguard. Persons or vessels at sea use the global maritime distress and safety systems (GMDSS) protocols. Her Majesty’s Coastguard have long standing arrangements with the Queen’s Harbour Master, Portsmouth (QHM) (and all Harbour Authorities) that allow for mutual communication and cooperation during search and rescue activities within harbour limits. Both organisations have direct dial telephone lines between each other and can also communicate on marine band radio frequencies within the GMDSS.”

    Source location

    2014-0093-Response-by-Maritime-Coastguard-Agency
    Page 1 · response
    Published 3 March 2014

    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

    Existing HM Coastguard and harbour-authority communication, cooperation and rescue-coordination arrangements are sufficient within harbour limits.

    Verbatim wording from the response

    “The formal protocols, for persons on land, for the alerting of HM Coastguard are by calling 999 and ask for coastguard. Persons or vessels at sea use the global maritime distress and safety systems (GMDSS) protocols. Her Majesty’s Coastguard have long standing arrangements with the Queen’s Harbour Master, Portsmouth (QHM) (and all Harbour Authorities) that allow for mutual communication and cooperation during search and rescue activities within harbour limits. Both organisations have direct dial telephone lines between each other and can also communicate on marine band radio frequencies within the GMDSS.”

    Source location

    2014-0093-Response-by-Maritime-Coastguard-Agency
    Page 1 · response
    Published 3 March 2014

    Open published response

  6. North London

    AI-generated summary

    Adrian Anthony Cowan · 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

    Adrian Anthony Cowan, who was detained under the Mental Health Act 1983, had a seizure on 14 June 2012 and was later found unresponsive in his room after being observed breathing normally. The inquest recorded natural causes, with pulmonary thromboembolism and deep vein thrombosis as the medical cause of death, alongside epilepsy and diabetes. Concerns related to unclear emergency-response guidance, including the failure to require the duty doctor to attend, and staff difficulties in responding calmly and applying basic life-support training.

    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 nursing staff to respond to collapses in a calm coordinated manner

    Wider context from the report

    “(2) Some of the nursing staff were not able, when responding to Mr Cowan being found collapsed, act in a calm coordinated manner and were not able to apply the training they had received in basic life support. ”

    Source location

    Adrian Anthony Cowan · 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

    Display step-by-step breathing-assessment and emergency-response guidance across all Forensic Service ward areas.

    Verbatim wording from the response

    “I would like to clarify that the Trust’s resuscitation policy in place at the time of Mr Cowan’s death did list the actions to be taken to determine whether a patient was breathing or not, and explained what action was to be taken in such events. We have now displayed this step by step guide within all ward areas within the Forensic Service, and we will be introducing this in all our other inpatient areas. I would further wish to reassure you that the training provided to frontline staff will reiterate the changes in our policy once it has been ratified which I anticipate will have been completed by 30th April 2014.”

    Source location

    2014-0111-Response
    Page 2 · response
    Published 7 February 2014

    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

    Introduce the step-by-step emergency-response guide in all other inpatient areas.

    Verbatim wording from the response

    “I would like to clarify that the Trust’s resuscitation policy in place at the time of Mr Cowan’s death did list the actions to be taken to determine whether a patient was breathing or not, and explained what action was to be taken in such events. We have now displayed this step by step guide within all ward areas within the Forensic Service, and we will be introducing this in all our other inpatient areas. I would further wish to reassure you that the training provided to frontline staff will reiterate the changes in our policy once it has been ratified which I anticipate will have been completed by 30th April 2014.”

    Source location

    2014-0111-Response
    Page 2 · response
    Published 7 February 2014

    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

    Revise and regularly run lifelike-manikin resuscitation assessments and practical sessions across Forensic Service and Trust wards.

    Verbatim wording from the response

    “In order to improve the confidence and competence of staff’s application of resuscitation techniques, regular assessments and practical sessions have been implemented using a lifelike manikin, designed to offer a highly realistic platform for the teaching of resuscitation. This approach is being revised and will in future be run regularly across all wards within the Forensic Service and the Trust. I have asked our Resuscitation Officer to conduct unannounced resuscitation scenarios across the Forensic wards so that we may further strengthen staffs ability to respond in an emergency situation.”

    Source location

    2014-0111-Response
    Page 2 · response
    Published 7 February 2014

    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

    Conduct unannounced resuscitation scenarios across Forensic wards to strengthen emergency response.

    Verbatim wording from the response

    “In order to improve the confidence and competence of staff’s application of resuscitation techniques, regular assessments and practical sessions have been implemented using a lifelike manikin, designed to offer a highly realistic platform for the teaching of resuscitation. This approach is being revised and will in future be run regularly across all wards within the Forensic Service and the Trust. I have asked our Resuscitation Officer to conduct unannounced resuscitation scenarios across the Forensic wards so that we may further strengthen staffs ability to respond in an emergency situation.”

    Source location

    2014-0111-Response
    Page 2 · response
    Published 7 February 2014

    Open published response

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