Recurring concern

Unreliable equipment for ambulance transfer of patients

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First reported 17 Apr 2014•Latest report 19 May 2025

Definition

What this concern includes

Includes failures of equipment and dedicated equipment-compatibility controls used to lift, move, secure or transfer patients to or between ambulances, including equipment function, availability, suitability and confirmation that equipment fits the ambulances used.

Not included

  • Excludes general patient moving and handling failures where ambulance-transfer equipment is not the identified unsafe condition.
  • Excludes ambulance response, dispatch, hospital handover and clinical-treatment failures unrelated to the equipment used for patient transfer.
  • Excludes generic equipment maintenance or stock deficiencies unless they directly affect equipment used for ambulance patient transfer.
  • Excludes transfer-planning, staffing or communication failures where no ambulance-transfer equipment or compatibility deficiency is identified.
Reports
3

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
4

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

East of England Ambulance Service NHS Trust1
Kent Central Ambulance Service Ltd1
Royal Cornwall Hospitals NHS Trust1

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. North East Kent

    AI-generated summary

    Emily Rose STOKES · 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

    Emily Stokes, a 17-year-old looked after child, became critically unwell after apparently taking MDMA at a music festival and died after suffering a cardiac arrest in hospital. Concerns included limited training of private ambulance staff in managing illicit substance use, unclear responsibility for pre-alerting the hospital, and ambulance equipment that was less comprehensive than that of an NHS ambulance.

    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

    Insufficient equipment on private ambulances for patient transfer and care

    Wider context from the report

    “(3)The ambulance did not have the same equipment which an NHS Ambulance would have on board and was in essence very little more than a means of transport from the venue to the hospital and may have given a false sense of reassurance. ”

    Source location

    Emily Rose STOKES · 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

    Use a pre-event vehicle checklist to standardise and document equipment preparation.

    Verbatim wording from the response

    “Action Taken:”

    Source location

    Response from Kent Central Ambulance Service
    Page 6 · response
    Published 28 July 2025

    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

    Develop and benchmark a clinical inventory standard against NHS specifications.

    Verbatim wording from the response

    “Action Taken:”

    Source location

    Response from Kent Central Ambulance Service
    Page 6 · response
    Published 28 July 2025

    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

    Distribute an event-readiness checklist covering equipment, clinical signs, contacts, escalation, hospital pre-alerts and documentation.

    Verbatim wording from the response

    “6. Deployment of Event Readiness Checklist”

    Source location

    Response from Kent Central Ambulance Service
    Page 7 · response
    Published 28 July 2025

    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 vehicle had equipment considered appropriate for the authorised scope of care, despite not necessarily matching NHS ambulance specifications.

    Verbatim wording from the response

    “The vehicle used was a High Dependency Vehicle (HDV) and was staffed by a crew of two staff members. The vehicle was equipped with monitoring equipment, oxygen, resuscitation tools, and all other kit deemed appropriate for the level of care authorised under their scope.”

    Source location

    Response from Kent Central Ambulance Service
    Page 6 · response
    Published 28 July 2025

    Open published response
  2. Norfolk

    AI-generated summary

    ROBERT CHARLES CHANDLER · 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

    Robert Charles Chandler collapsed and suffered a pneumothorax on 24 September 2018. An ambulance arrived 50 minutes after the first telephone call, and he died in hospital on 25 September 2018 from his injury. Concerns included equipment failure and transfer without pain relief or safety straps, incomplete records, inconsistent equipment checks and assistance-seeking, and delayed implementation of investigation recommendations.

    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 inflatable lifting-chair sections to inflate

    Wider context from the report

    “(1) The Mangar Elk inflatable chair was intended to be used to lift Mr Chandler to the ambulance. One section did not inflate and so Mr Chandler was lifted underneath his arms and transferred to a chair borrowed from a local supermarket, no pain relief was given to Mr Chandler before being placed into the ambulance. He was later diagnosed with a pneumothorax. No safety straps were used. ”

    Source location

    ROBERT CHARLES CHANDLER · 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 use safety straps during patient transfer

    Wider context from the report

    “(1) The Mangar Elk inflatable chair was intended to be used to lift Mr Chandler to the ambulance. One section did not inflate and so Mr Chandler was lifted underneath his arms and transferred to a chair borrowed from a local supermarket, no pain relief was given to Mr Chandler before being placed into the ambulance. He was later diagnosed with a pneumothorax. No safety straps were used. ”

    Source location

    ROBERT CHARLES CHANDLER · 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

    Repair the identified faulty Mangar Elk equipment.

    Verbatim wording from the response

    “You will appreciate that equipment can malfunction at times and we do have a process in place in order to manage these issues. Unfortunately on this occasion the individual did not raise an incident at the time, although I can confirm the equipment was identified as faulty and fixed. I will ensure that further investigation takes place in relation to the clinician’s statement that the equipment malfunction was reported as an incident.”

    Source location

    2019-0060-Response-by-East-of-England-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 26 May 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

    Annual servicing and the Medical Devices Policy are considered sufficient to manage Mangar Elk faults.

    Verbatim wording from the response

    “Mangar Elk malfunction The Mangar Elk equipment is used by staff in order to assist patients who have fallen. All devices are serviced on an annual basis in line with the manufacturer guidelines. If a fault is detected then it is managed in line with our Medical Devices Policy and either reported on our incident reporting system or tagged as faulty. It is then assessed by our Clinical Engineering Department and fixed as required.”

    Source location

    2019-0060-Response-by-East-of-England-Ambulance-Service-NHS-Trust
    Page 1 · response
    Published 26 May 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

    Testing Mangar Elk function during daily vehicle checks is considered impracticable because inflation and deflation would delay responses.

    Verbatim wording from the response

    “Vehicle/equipment daily checks The Trust has a process in place for vehicle/equipment daily checks to take place before the start of every shift. The vehicle daily checklist is completed by the crew and identifies any issues with the equipment on the vehicle. There are some exceptions to this if the crew are required to attend to the call immediately, however the general practice is to complete a vehicle daily check prior to the start of shift. It should also be noted that although a check list would identify that this particular piece of equipment is on the vehicle, it would not be practicable to test the function during this check due to the time taken to both inflate and deflate the device prior to responding to any incidents awaiting attendance”

    Source location

    2019-0060-Response-by-East-of-England-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 26 May 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

    Safety for Mangar Elk use is considered adequately managed by attending ambulance staff, despite the equipment lacking safety straps.

    Verbatim wording from the response

    “In terms of your comments regarding pain relief and safety straps, Entonox is not indicated with potential chest injuries so IV cannulation would be needed to administer the drug. The crew felt to do this they would need to take many layers of clothes off the patient in a cold outside area and it was more appropriate to complete when in the ambulance. The Mangar Elk piece of equipment does not have safety straps attached to it as the safety element is managed by the attending ambulance staff.”

    Source location

    2019-0060-Response-by-East-of-England-Ambulance-Service-NHS-Trust
    Page 2 · response
    Published 26 May 2019

    Open published response
  3. Plymouth, Torbay & South Devon

    AI-generated summary

    Karen Lesley Peters · 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

    Karen Peters suffered a fall and head injury in hospital on 28 March 2013, subsequently developing an acute subdural haemorrhage and dying on 29 March 2013 after delays in transfer to neurosurgical care. Concerns included nursing staffing and agency staff deployment, handover quality, neurological observations and escalation, administration of contraindicated anticoagulation, availability of airway support, and delays and coordination issues affecting time-critical transfer.

    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

    Uncertainty about compatibility of transfer equipment with available ambulances

    Wider context from the report

    “3. Transfer of time critical patients I heard from ████████ at Inquest who had been tasked to conduct a review of out of Hospital transfer from RCHT. On this occasion he found two factors that delayed the team: (a) Equipment was stored in a general cupboard and it took time to identify the right leads and other apparatus that was required; (b) Karen was intubated and ventilated in Theatre which threw off the relevant staff as they were not accustomed to dealing with patients in this way. I heard from ████████████████ that since this incident, all of the transfer equipment has been replaced. There is no further action for you to take in this regard. I also heard that, where possible, patients will now be prepared for transfer in the Emergency Department. I would like to know whether that is, in fact, working. Over the past year, how many patients have been prepared for time critical out of Hospital transfer other than in the Emergency Department? Why has this occurred and what can be done to address the issue? I also heard evidence from Paramedics who attended to carry out the transfer. They were unaware that RCHT had replaced its transfer equipment. It seemed to be that the efficacy of transfers could be improved if the service between Hospital Clinicians and Paramedics could be better joined up. Are any joint drills run? Is it known for certain that the new transfer equipment (attached to a specific stretcher) will fit in all of the ambulances available to South West Ambulance Trust? Is there a need for a particular type of Ambulance to be identified at the time that the doctor calls an ambulance? ”

    Source location

    Karen Lesley Peters · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026