Recurring concern

Unreliable emergency access arrangements for responders

Get email alerts

Request correction

First reported 1 Apr 2014•Latest report 20 Feb 2026

Definition

What this concern includes

Includes failures of dedicated arrangements that enable emergency responders to locate, plan access to and safely reach an incident, including hazardous or impracticable access routes and inadequate integrated electronic aids for location, route planning or safe passage.

Not included

Excludes ambulance-only access failures where the concern is confined to ambulance crews gaining entry to care or emergency-treatment premises.
Excludes emergency forced-entry arrangements concerning lawful entry into enclosed premises where the shared issue is authority or responsibility for forced entry rather than reaching the incident location.
Excludes generic emergency response, dispatch, communication or equipment failures that do not directly impair responder access to the incident location.
Excludes ordinary public access, pedestrian routes or workplace access hazards without an emergency-responder access function.

Reports: 14
Individual concerns: 15
Date range: 2014–2026
Stated actions: 21

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.

Serco Group plc2

Bournemouth Churches Housing Association Limited1

Daryel Care1

Department of Health and Social Care1

FirstPort Retirement Property Services Limited1

HCRG Care Ltd1

Health and Safety Executive1

Independent Office for Police Conduct1

Leeds City Council1

London Borough of Camden1

London Borough of Islington1

Metropolitan Police Service1

Northumbria Police1

Norwich Prison1

Recipient name withheld1

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.

18 Mar2015
County Durham and Darlington
Concerns raised1
1. Failure of emergency call location systems to accurately locate incidents
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.
Actions described in response 2
1. Action
  Review the feasibility of increasing Gazetteer and map update frequency.
  Stated by North East Ambulance Service NHS Foundation TrustStated in progress
2. Action
  Introduce a mobilising and communications system with integral caller-location mapping in the emergency control room.
  Stated by County Durham and Darlington Fire and Rescue ServiceStated completed
AI-generated summary

Grant Thomas Benson and Gordon Nicky Davidson · 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

Grant Thomas Benson and Gordon Nicky Davidson were travelling in a motor vehicle that crashed into a tree. The passenger died at the time of the collision or soon afterwards, while the driver survived the impact but died in the ensuing fire. The report identified shortcomings in emergency call handling and cross-boundary coordination, which delayed the dispatch of emergency services, although the evidence was that a prompt local response would not have changed the driver’s outcome in this case.

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 emergency call location systems to accurately locate incidents
Wider context from the report
“Between the time of the impact and him being incapable of further speech the driver had a conversation with an Ambulance Control call handler with a view to securing the attendance of the Emergency Services. This call lasted for several minutes and it is clear from listening to the recording how frantic the driver became as the fire began and took hold. The driver gave quite an accurate description of his approximate location to the call handler but the call handler was unable at any time during the call to accurately locate the whereabouts of the incident. Technological information given by GPS gave an inaccurate location for the incident. The emergency call was routed to Yorkshire Ambulance Service rather than to North East Ambulance Service which would have been based in Newcastle Upon Tyne. The call handler with Yorkshire ambulance Service was based in Wakefield. She had no personal knowledge of the area. Despite having a map in front of her and the assistance of two other members of staff looking over her shoulder and trying to assist it was not possible for an ambulance to be dispatched. The call handler in evidence said that she repeated certain key information to the caller but that is not recorded. She gave evidence that she would have covered the microphone to speak to colleagues in trying to locate the incident. Her evidence was inconsistent. It is accepted in evidence that an option might have been to have sought further and urgent advice from a more local agency, the North East Ambulance Trust or possibly Durham Police or Durham and Darlington Fire Rescue Service. Evidence was given that it is not possible to transfer responsibility for calls from one emergency service to another and the only means of further communication would be by telephone evidence was clear that in cross boundary area situations there are inadequate systems in place to ensure the best possible response to an incident. It is not possible for one ambulance service to dispatch an ambulance from another ambulance service. Evidence was given that a suitable ambulance had been identified to be sent to this incident based at Richmond North Yorkshire with an estimated journey time of 28 minutes. There was an ambulance station situated in Barnard Castle (and incidentally a Police Station and Fire Station) which is only some 5 minutes or so travelling time away from the incident location. Because of the difficulties in establishing an exact location, at no time did Yorkshire Ambulance have sufficient information to despatch an ambulance. Emergency services only attended the scene of the incident once a further call had been made to the Emergency Services by a member of the public. The evidence in this case was that even if the local Fire Brigade had been promptly summoned, an appropriate appliance would not have reached the incident scene sufficiently quickly to have changed the outcome i.e. the death of the driver. The evidence however, reveals system shortcomings which may in other circumstances lead to avoidable deaths taking place and therefore a review by the Emergency Services of a joined up approach could be particularly useful, in addition to a comprehensive review of call handling procedures in difficult circumstances such as these. ”
Source location
Grant Thomas Benson and Gordon Nicky Davidson · 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
Review the feasibility of increasing Gazetteer and map update frequency.

Verbatim wording from the response
“The Trust uses northings and eastings co-ordinates to map the location of calls alongside a Gazetteer pulling addresses from telephone landlines. Currently it is being reviewed as to the feasibility of increasing the frequency of Gazetteer and map updates for all Ambulance Trusts.”

Source location
2015-0102-Response-by-North-East-Ambulance-Service-NHS-Trust
Page 1 · response
Published 18 March 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
Introduce a mobilising and communications system with integral caller-location mapping in the emergency control room.

Verbatim wording from the response
“1 Inability to Dispatch Resources without Identifying Exact Location on Mapping System In December 2014 CDDFRS introduced a new state of the art mobilising and communications system into their emergency control room. Prior to the introduction of this system control personnel would extract incident location information from callers using interrogation techniques given to them during initial training and induction.”

Source location
2015-0102-Response-by-Fire-Rescue-Service
Page 1 · response
Published 18 March 2015
Open published response
2 Feb2015
Norfolk
Concerns raised1
1. Failure to ensure Code Blue responders know where to go
This report raised 1 other concern. 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 5
1. Action
  Revise new-starter and agency-staff induction to include prison-wide shadowing.
  Stated by HCRG Care Services LtdStated completed
2. Action
  Develop and introduce a local induction process and checklist to record completion.
  Stated by HCRG Care Services LtdStated in progress
3. Action
  Provide annual refresher training on prison layout and emergency attendance procedures.
  Stated by HCRG Care Services LtdStated planned
1. Action
  Arrange for prison officers to meet nurses at the entrance corridor and direct them to medical emergencies during patrol state.
  Stated by HCRG Care Services LtdStated completed
2. Action
  Ratify a joint medical-emergency response protocol with HMP Norwich.
  Stated by HCRG Care Services LtdStated planned
Respondent positions 3
1. Position
  Serco no longer provides services at HMP Norwich and has no power to implement the recommendations there.
  Stated by Mr Rupert SoamesOutside remit
1. Position
  HMP Norwich and Virgin Care have the power to implement the recommendations.
  Stated by Mr Rupert SoamesRedirects responsibility
2. Position
  Prison maps cannot be introduced because the prison governor does not permit them for security reasons.
  Stated by HCRG Care Services LtdUnable to act
AI-generated summary

DARREN WRIGHT · 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

Darren Wright, aged 35, was found dead in his cell at HMP Norwich on 3 November 2013 after having been admitted to prison in September 2013. The report identified concerns about inconsistent sharing and access to information, the response to a Code Blue notification, and gaps in recent CPR training among attending prison officers.

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 ensure Code Blue responders know where to go
Wider context from the report
“(1) On receiving Code Blue notification the Staff Nurse did not know where to go and had to call on her radio to be found and then taken to the cell; ”
Source location
DARREN WRIGHT · 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
Revise new-starter and agency-staff induction to include prison-wide shadowing.

Verbatim wording from the response
“In terms of training, all new nurses working in HMP Norwich are required to undergo a two week ‘shadow’ period where they are fully inducted to all areas of the prison. During this time, emergency response kits are highlighted to staff. This amended process for shadowing of new staff was already in place on 1 April 2014 when Virgin Care’s contract to provide the service came into force. Unfortunately, whilst we did consider introducing maps of the prison to assist our staff in locating cell numbers, this is not permitted by the prison governor for security reasons in prisons.”

Source location
2015-0035-Response-by-Virgin-Care-Services-Limited
Page 2 · response
Published 2 February 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
Develop and introduce a local induction process and checklist to record completion.

Verbatim wording from the response
“• The induction process has been reviewed and revised to include ‘shadowing’ time for all new starters and agency staff. To further evidence this, a local induction process and checklist template is being developed and introduced to record an individual’s completion of this process. This will therefore increase the knowledge of our staff in terms of the layout of cells when they are required to attend an emergency. This will be followed up with refresher training on an annual basis.”

Source location
2015-0035-Response-by-Virgin-Care-Services-Limited
Page 2 · response
Published 2 February 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
Provide annual refresher training on prison layout and emergency attendance procedures.

Verbatim wording from the response
“• The induction process has been reviewed and revised to include ‘shadowing’ time for all new starters and agency staff. To further evidence this, a local induction process and checklist template is being developed and introduced to record an individual’s completion of this process. This will therefore increase the knowledge of our staff in terms of the layout of cells when they are required to attend an emergency. This will be followed up with refresher training on an annual basis.”

Source location
2015-0035-Response-by-Virgin-Care-Services-Limited
Page 2 · response
Published 2 February 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
Arrange for prison officers to meet nurses at the entrance corridor and direct them to medical emergencies during patrol state.

Verbatim wording from the response
“• A review of the response procedure – the Head of Healthcare at HMP Norwich has met with the Operations Governor within the prison and agreed where a medical emergency arises when the prison is in patrol state, a prison officer will wait for the nurse in the entrance corridor and direct the nurse to the medical emergency. This has already been put into place and a joint protocol will be ratified by both ourselves and HMP Norwich by 31 March 2015. This will ensure that our nurses can be directed to the correct cell to attend to medical emergencies.”

Source location
2015-0035-Response-by-Virgin-Care-Services-Limited
Page 2 · response
Published 2 February 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
Ratify a joint medical-emergency response protocol with HMP Norwich.

Verbatim wording from the response
“• A review of the response procedure – the Head of Healthcare at HMP Norwich has met with the Operations Governor within the prison and agreed where a medical emergency arises when the prison is in patrol state, a prison officer will wait for the nurse in the entrance corridor and direct the nurse to the medical emergency. This has already been put into place and a joint protocol will be ratified by both ourselves and HMP Norwich by 31 March 2015. This will ensure that our nurses can be directed to the correct cell to attend to medical emergencies.”

Source location
2015-0035-Response-by-Virgin-Care-Services-Limited
Page 2 · response
Published 2 February 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
Serco no longer provides services at HMP Norwich and has no power to implement the recommendations there.

Verbatim wording from the response
“Whilst at the time of Mr Wright's unfortunate death Serco was the healthcare provider at HMP Norwich, as from 1st April 2014 all responsibility for delivery of healthcare services passed to Virgin Care. Accordingly, Serco no longer have any involvement in service delivery at HMP Norwich.”

Source location
2015-0035-Response-by-Serco
Page 1 · response
Published 2 February 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
HMP Norwich and Virgin Care have the power to implement the recommendations.

Verbatim wording from the response
“As stated above, Serco does not provide any services to HMP Norwich (either custodial or healthcare). Therefore, the company has no power to implement these recommendations at HMP Norwich. However, we note that the Regulation 28 report has been sent to HMP Norwich and Virgin Care Limited and these parties do have power to implement the recommendations.”

Source location
2015-0035-Response-by-Serco
Page 1 · response
Published 2 February 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
Prison maps cannot be introduced because the prison governor does not permit them for security reasons.

Verbatim wording from the response
“In terms of training, all new nurses working in HMP Norwich are required to undergo a two week ‘shadow’ period where they are fully inducted to all areas of the prison. During this time, emergency response kits are highlighted to staff. This amended process for shadowing of new staff was already in place on 1 April 2014 when Virgin Care’s contract to provide the service came into force. Unfortunately, whilst we did consider introducing maps of the prison to assist our staff in locating cell numbers, this is not permitted by the prison governor for security reasons in prisons.”

Source location
2015-0035-Response-by-Virgin-Care-Services-Limited
Page 2 · response
Published 2 February 2015
Open published response
14 Jan2015
Inner South London
Concerns raised1
1. Barricading of rave venues against police and other emergency access
This report raised 8 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

Max Carlton-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

Max Carlton-Smith died after taking MDMA at an illegal rave and collapsing when emergency medical assistance was not summoned immediately. The rave had no on-site medical assistance, inadequate ventilation, and unregulated fire exits and procedures; the report also raised concerns about delays in calling an ambulance and the authorities’ ability to intervene at the squatted commercial premises.

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
Barricading of rave venues against police and other emergency access
Wider context from the report
“The organizers of the unlicensed rave had not provided on-site medical assistance and had spent between 12 and 42 minutes before calling the ambulance service, when the deceased collapsed. There was inadequate ventilation for a very hot venue, and fire exits and procedure had not been regulated. The organizers had taken over an empty squatted commercial building and barricaded against those who attempted to enter, (including police, who attended and spoke earlier to a security man and then later following complaints of noise). I concluded that had the event been licensed and normal facilities and regulation in place, he would probably not have died when he did. ”
Source location
Max Carlton-Smith · Prevention of Future Deaths report
Page 1 · concerns
Open source report
1 Apr2014
Gateshead and South Tyneside
Concerns raised1
1. Failure to provide integrated electronic aids for location, route planning and safe passage
This report raised 9 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

Vincent Gibson · 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

Vincent Gibson was fatally injured while crossing Whiteleas Way, South Shields, when he was struck by a police vehicle travelling at speed in response to a Grade 1 emergency call. The principal concerns related to inadequate coordination, management, monitoring and control of the incident, including the failure to communicate that the caller remained in contact with the call taker, unclear roles, insufficiently informed risk assessment, resource allocation, route planning and uncertainty about response speed.

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 provide integrated electronic aids for location, route planning and safe passage
Wider context from the report
“Electronic aids are a benefit not only to Central Control but also to responders and such electronic aids should eliminate any issue or debate around the fact as to route and leave the crew speculating as to the position, route or speed. 10. Electronic aids should (a) readily identify the location (b) pre-plan the route (c) determine a safe and where appropriate speedy passage. In any event, any electronic aids and/or systems must be fully integrated being identified for the purpose they are intended to serve. ”
Source location
Vincent Gibson · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure of emergency call location systems to accurately locate incidents

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.2

Concerns raised1

Failure to ensure Code Blue responders know where to go

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.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Barricading of rave venues against police and other emergency access

Concerns raised1

Failure to provide integrated electronic aids for location, route planning and safe passage

Actions described in response 2

Actions described in response 5

Respondent positions 3