Recurring concern

Failure to reliably notify receiving hospital staff of ambulance arrivals

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First reported 10 Jul 2015•Latest report 1 Sep 2023

Definition

What this concern includes

Includes failures of the dedicated process for notifying receiving hospital trusts, units or clinicians about ambulance presence or the arrival of expected patients, including failures to notify relevant receiving doctors or to relay material context needed for immediate coordination.

Not included

Excludes ambulance dispatch, triage, attendance and hospital handover delays where the specific failure is not notification of arrival to receiving hospital staff.
Excludes general clinical information-sharing failures without a receiving-hospital-arrival notification context.
Excludes failures to notify patients, families, coroners, probation services or other recipients unrelated to receiving hospital staff.
Excludes failures occurring after receiving staff have been reliably notified, including subsequent assessment, treatment or admission delays.

Reports: 3
Individual concerns: 3
Date range: 2015–2023
Stated actions: 1

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care2

Family of the deceased1

NHS Lancashire and South Cumbria Integrated Care Board1

North West Ambulance Service NHS Trust1

United Lincolnshire Teaching Hospitals NHS Trust1

Weightmans LLP1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

1 Sep2023
Blackpool and the Fylde
Concerns raised1
1. Failure to notify receiving doctors when patients arrive at the hospital
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Direct referred Emergency Department patients to the admissions area, contact receiving specialty teams, and require specialty assessment when no admission capacity exists.
  Stated by NHS Lancashire and South Cumbria Integrated Care BoardStated completed
Respondent positions 1
1. Position
  Specific local actions addressing the concerns are the responsibility of Lancashire and South Cumbria Integrated Care Board.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Harold Derek PEDLEY Otherwise known as Derek PEDLEY · 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

Harold Derek Pedley, known as Derek, attended hospital after referral by his GP with abdominal pain and vomiting, but remained in the Emergency Department waiting area for almost two hours without being assessed or spoken to by a medical professional, and died before he was called. The report raised concerns about hospital pressures at OPEL 4, the inability to triage patients and notify expecting doctors, and the risk that patients may arrive expecting prompt assessment when this cannot be provided.

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 notify receiving doctors when patients arrive at the hospital
Wider context from the report
“• Concern 1 – that the medical professionals who work in a hospital emergency department are routinely expected to do so when the OPEL 4 applies, a recognition they are performing their roles when the hospital is “unable to deliver comprehensive care, and patient safety is at risk”. Such pressures may serve to leave the Emergency Department unable to triage patients such as Derek, and have no time to notify the doctors expecting his arrival (in this case doctors on the Surgical Assessment Unit) who are consequently left unaware that a patient has in fact arrived, all of which serves to place vulnerable patients such as Derek Pedley at serious risk. ”
Source location
Harold Derek PEDLEY Otherwise known as Derek PEDLEY · Prevention of Future Deaths report
Page 4 · 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
Direct referred Emergency Department patients to the admissions area, contact receiving specialty teams, and require specialty assessment when no admission capacity exists.

Verbatim wording from the response
“As a result of the learning from this case Blackpool Victoria Hospital have revised their processes now so that if a patient arrives in the Emergency Department and has already been referred for example to the surgical team, then the patient is now directed to the admissions area. If the patient has already been accepted by the specialty, then the reception team at the Fylde Coast Medical Service (FCMS), or the streaming or triage nurse contact the receiving area, and if there is capacity then the patient is transferred to receiving speciality team. If there is no capacity in the admission area, the ED nursing or medical team will communicate directly with the speciality team and inform them of the patient’s arrival.”

Source location
Response from Lancashire and South Cumbria Integrated Care Board
Page 3 · response
Published 8 September 2023
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
Specific local actions addressing the concerns are the responsibility of Lancashire and South Cumbria Integrated Care Board.

Verbatim wording from the response
“I understand that Lancashire and South Cumbria Integrated Care Board have responded to you directly on the specific actions being taken locally to address the concerns you have raised. Further, the CQC has advised my officials that they continue to have regular engagement with Blackpool Teaching Hospitals NHS Foundation Trust to monitor waiting time performance and risk.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 8 September 2023
Open published response
23 Jan2019
Lincolnshire
Concerns raised1
1. Failure to forewarn obstetric and gynaecology clinicians of emergency arrivals
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Gail Bailey · 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

Gail Bailey, who was nine weeks pregnant, developed abdominal discomfort while on holiday on 5 August 2017. An ambulance was called but arrived after a delay, and she was declared deceased at Boston Pilgrim Hospital later that evening. The report raised concerns about emergency communication and preparedness, including pre-alert calls that were not dated or signed and the apparent lack of advance warning to obstetric and gynaecology staff.

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 forewarn obstetric and gynaecology clinicians of emergency arrivals
Wider context from the report
“C) I received evidence from Mr Bailey that upon arrival at hospital the clinicians appeared not to be ready for his wife's arrival. D) I received evidence from Mr ████████, consultant in the Accident and Emergency Unit at Boston Pilgrim Hospital, that ████████, a Specialty Doctor in Emergency medicine present at the time had noted in the medical records that he, together with other doctors had attempted to resuscitate Mrs Bailey who had presented to A & E in a collapsed state around 21.00 hours and had noted that "a cardiac arrest call-out had also been initiated in or around the time of the patients' arrival to Pilgrim." E) I received evidence from the locum registrar for the labour ward, ████████ that "[My understanding at that time was that] no Obstetrician and gynaecologist was forewarned about this patients arrival to the A & E department." F) The ED records confirmed that two pre alert calls were recorded but not dated nor signed. G) Whilst the severity of Mrs Bailey's condition meant that in the particular circumstances of this case the treatment Mrs Bailey received at hospital neither caused nor contributed to her death, the apparent breakdown in communication does raise an area of concern in relation to future emergency admissions. ”
Source location
Gail Bailey · Prevention of Future Deaths report
Page 2 · concerns
Open source report
10 Jul2015
Manchester North
Concerns raised1
1. Failure to notify the hospital trust of ambulance presence within hospital grounds
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 2
1. Position
  The Department considers the concerns matters for local comment and resolution rather than national action.
  Stated by Department of Health and Social CareOutside remit
1. Position
  Specific concerns should be redirected to Fairfield General Hospital for consideration after North West Ambulance Service’s response.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Colin Moulton · 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

Colin Moulton was discovered deceased on 14 February 2013 near the perimeter wall of the Irwell Unit at Fairfield General Hospital, after leaving the Accident and Emergency Department the previous day. Concerns included ineffective communication during handover, incorrect triage, failure to recognise confusion, and the absence of a formal capacity assessment or other documented measures when he attempted to leave. The inquest narrative stated that his death was contributed to by neglect.

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 notify the hospital trust of ambulance presence within hospital grounds
Wider context from the report
“2. At approximately 5pm on the 13th February 2013, a number of administrative staff, whilst en-route home saw Colin Moulton within the hospital grounds near to the Irwell Unit. They perceived him to be ‘ in difficulty’. One of the staff members called for the assistance of an ambulance which duly attended and a paramedics on board apparently were unable to locate Mr Moulton. Had the Ambulance Trust notified the Hospital Trust of their presence within the hospital grounds, this may have tied in with earlier concerns in relation to Mr Moulton of which the Hospital Trust was aware. The Ambulance Trust is requested to consider whether in the future, third parties such as Hospital Trusts might be notified in such circumstances. ”
Source location
Colin Moulton · Prevention of Future Deaths report
Page 2 · 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
The Department considers the concerns matters for local comment and resolution rather than national action.

Verbatim wording from the response
“I consider that both of your concerns are for local comment and resolution and I note that you have sent a copy of your report to the NWAS. I am aware that NWAS has already responded, addressing the issues you raise and asking that you redirect your specific concerns to FGH for its consideration also.”

Source location
2015-0267-Response-by-Department-of-Health
Page 1 · response
Published 10 July 2015
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
Specific concerns should be redirected to Fairfield General Hospital for consideration after North West Ambulance Service’s response.

Verbatim wording from the response
“I consider that both of your concerns are for local comment and resolution and I note that you have sent a copy of your report to the NWAS. I am aware that NWAS has already responded, addressing the issues you raise and asking that you redirect your specific concerns to FGH for its consideration also.”

Source location
2015-0267-Response-by-Department-of-Health
Page 1 · response
Published 10 July 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to notify receiving doctors when patients arrive at the hospital

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to forewarn obstetric and gynaecology clinicians of emergency arrivals

Concerns raised1

Failure to notify the hospital trust of ambulance presence within hospital grounds

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 1

Respondent positions 1

Respondent positions 2