9 Dec 2019 John Michael WELLS · Prevention of Future Deaths report West Sussex
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Concerns raised 1
Different ambulance-call handling for third-party callers View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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John Michael WELLS · 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
John Michael Wells died at the scene after lacerating a varicose vein and suffering severe blood loss while prescribed anticoagulant medication. The report identified concerns about incomplete medical information, the accessibility and handling of responder contact details, the absence of automatic risk flagging, and the triage of third-party emergency calls.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Different ambulance-call handling for third-party callers
Wider context from the report “(4) Under NHS Pathways triage system ambulance calls received from third party callers are handled in a different way from those received from persons present with a patient.
The SECAMB SIR identified that the receipt of a call from a third party was a contributory factor, partly as it required a first party call back . Mr Wells stated he was not able to talk to the ambulance service on the telephone.
From the evidence before the inquest it was clear that the Appello operator was still connected to Mr Wells when in contact with SECAMB. However there was no way for the operator pass the call though thereby allowing direct contact between Mr Wells and the SECAMB EMA.
” Source location John Michael WELLS · Prevention of Future Deaths report
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9 Jul 2019 Allan Davies · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Failure of NHSP overdose triage to account for drug type and sudden-collapse risk View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
NHS England
Introduce and ratify disposition code Dx0124 to identify higher-risk suicidal patients for early clinical review.
View source
NHS England
Deploy NHS Pathways Release 18 across NHS 111 and participating ambulance services, including staff updates and system implementation.
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NHS England
Develop a proposed disposition code to identify symptomatic, non-suicidal overdose patients for urgent clinical assessment.
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Allan 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
Allan Davies, who had a history of illicit drug misuse, telephoned 999 after unintentionally taking heroin, crack cocaine and mamba. Although he initially reported breathlessness, the ambulance response was delayed as dispatched ambulances were transferred to higher-category patients; he was later found in cardiac arrest and died, with the medical cause of death recorded as heroin overdose. The substantive concerns were that NHS Pathways triage treated overdose cases too generically, without regard to the drug taken and risk of sudden collapse, and that not all NHS trusts and ambulance services were aware of this deficiency.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of NHSP overdose triage to account for drug type and sudden-collapse risk
Wider context from the report “I heard evidence from a West Midlands Ambulance Service (WMAS) Clinical Standards Manager and Emergency Operations Centre Clinical Manager. They explained that it is recognised certain drugs put overdose patients who are initially breathing and conscious at greater risk of sudden collapse. An example given of the two ends of spectrum was a paracetamol overdose – less risk of sudden collapse – and heroin overdose – greater risk of sudden collapse. However, when an overdose patient calls 999, the NHS Pathways Telephone Triage System (NHSP) does not distinguish between the type of drug(s) taken and the corresponding risk of sudden collapse . If the patient is breathing and conscious at the time of the call, NHSP advises a category 3 response (ambulance within two hours), regardless of the type of drug(s) taken . Both witnesses expressed concern that this is too generic and is placing patients at risk.
One of the witnesses sits on the NHSP user group, and added the generic triaging of overdose cases continues despite a number of different NHS trusts sharing the same concern and raising it with NHS Pathways via the user group. WMAS are sufficiently concerned about the on-going concern that in January 2019 they implemented a local policy adding a layer of triaging on top of NHSP to have regard to the type of drug(s) taken and its impact on the patient.
My on-going concern is:
(1) NHSP triaging of overdose cases is too generic, namely it fails to have regard to the type of drug(s) taken and the potential for sudden collapse in certain patients ;
(2) Not all NHS trusts/ambulance services that utilise NHSP are aware of this apparent deficiency.
” Source location Allan Davies · Prevention of Future Deaths report
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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 and ratify disposition code Dx0124 to identify higher-risk suicidal patients for early clinical review.
Verbatim wording from the response “To support this recommendation NHS Pathways have introduced a new disposition code (Dx0124), ratified by the NHS Pathways National Clinical Governance Group (NCGG) in February 2019. This new code, ‘Dx0124 Emergency Ambulance Response for Risk of Suicide (Category 3)’ is designed to facilitate the early identification of higher risk suicidal patients either following an intentional toxic overdose or persons who intend to end their life by violent means, so that they can undergo early clinical review within 111 and 999 call-handling centres.” Source location 2019-0291-Response-by-NHS-Digital
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deploy NHS Pathways Release 18 across NHS 111 and participating ambulance services, including staff updates and system implementation.
Verbatim wording from the response “This new disposition code to support further clinical assessment was finalised and included in Release 18 of NHS Pathways content. Beta testing occurred in August 2019 and widescale deployment of Release 18 to all providers of NHS111 and all ambulance services in England that use the NHS Pathways system begins on 7th October 2019, with services then having an 8 week period to update their staff and deploy in their systems.” Source location 2019-0291-Response-by-NHS-Digital
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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 a proposed disposition code to identify symptomatic, non-suicidal overdose patients for urgent clinical assessment.
Verbatim wording from the response “NHS Pathways has also recognised that those patients who have overdosed without suicidal intent and have symptoms (and so receive a Dx012 disposition and Category 3 ambulance) would benefit from having the same visibility within the Category 3 cohort as those with suicidal intent, so they can also be easily identified by clinicians working within ambulance control rooms for urgent remote clinical assessment of the risk to life. Further work by the NHS Pathways team is commencing in this area and, subject to review by the National Clinical Governance Group, a new disposition code will be introduced (similar to Dx0124) to enable this to occur. The Ambulance Response Programme will be made aware of this proposed change.” Source location 2019-0291-Response-by-NHS-Digital
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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 Automated identification of higher-risk overdose patients is not currently possible because patients may inaccurately identify the substance or quantity taken.
Verbatim wording from the response “This letter also offered to promote and share good practice in this regard, which several ambulance services have done. This letter from ████████ followed earlier work to examine whether there might be a way of identifying higher risk overdose patients automatically, given that NHS Pathways is a computer-based system operated by non-clinical call handlers. However unfortunately no such system exists at present, not least because patients who have taken an overdose may not be able to identify accurately the substance or quantity that they have taken, and for this reason active clinical oversight within ambulance control rooms was recommended.” Source location 2019-0291-Response-by-NHS-England
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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 Reclassifying every overdose case as a Category 2 ambulance response would create wider clinical risks and delay responses to patients with greater need.
Verbatim wording from the response “I can confirm that the re-categorisation of all such cases from Dx012 (Category 3 ambulance) responses to a Category 2 ambulance response, without first differentiating the clinical risks of method, toxicity and social circumstance, was also considered. However given the large volume of low risk patients that would be included in such a change this would also introduce new clinical risks across the wider emergency care system and delay the ambulance response to other patients with greater need. Therefore again the introduction of a new code was felt to be the safest and best option.” Source location 2019-0291-Response-by-NHS-England
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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 Automatically identifying higher-risk overdose patients from drugs taken is not possible because telephone triage has too many variables for non-clinical call handlers.
Verbatim wording from the response “Overdose cases (whether with suicidal intent or not) are very complex to assess within telephone triage due to different methods, lethality and social circumstances. In overdose cases the capacity of any drug to cause harm is dependent on multiple factors; for example, quantity of drug taken, interactions of other medication, the patient’s medical history and time of overdose, as well as the patient’s understanding of what exactly has been taken.” Source location 2019-0291-Response-by-NHS-Digital
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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 Re-categorising all suicidal cases for faster ambulance responses would offer little benefit and could introduce wider clinical risks.
Verbatim wording from the response “4) Use of disposition Dx012 /Category 3 ambulance response” Source location 2019-0291-Response-by-NHS-Digital
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31 May 2019 Christopher Williams · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Lack of a neurological-deficit triage algorithm View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
EEAST
Work with the IAED to improve triage standards and identify protocol gaps requiring clinical support.
View source
EEAST
Meet the IAED, draft and submit a proposal for a neurological-deficit pathway in 999-call triage.
View source
EEAST
Send the neurological-deficit pathway proposal to NASMeD for consideration and support.
View source
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AI-generated summary
Christopher Williams · 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 Williams underwent a procedure to remove an infected foot-surgery screw and later developed severe leg pain, bilateral paraesthesia, worsening back pain, and suspected cauda equina. There were delays in ambulance attendance and Emergency Department admission, and concerns about incorrect call triage, failure to escalate his worsening condition, and communication about an arranged admission bed. His condition deteriorated with sepsis, multi-organ failure and worsening heart failure, and he died on 26 January 2019.
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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 neurological-deficit triage algorithm
Wider context from the report “(1) The amount of time taken for the ambulance to arrive which was markedly outside the Trust’s guidelines.
(2) The failure by the call handler to both escalate Mr Williams worsening condition and her incorrect use of the haemorrhage algorithm.
(3) When the ambulance transported Mr Williams to the NNUH he was kept on board the vehicle awaiting a space in the Emergency Department, despite a bed already arranged several hours before by the GP. This information was unknown to the crew and resulted in several hours delay in Mr Williams being investigated and treated which may have contributed to his death by sepsis.
The Trust’s Business Continuity Manager was unaware until the inquest that the call handler had erred in failing to escalate and in using the wrong algorithm. He gave evidence that the Trust does not have an algorithm dealing with neurological deficit only a question asking if the patient is conscious . Given that Mr Williams had paraesthesia to both legs and the GP’s concerns about cauda equina this would seem to be a potentially dangerous gap in the Trust’s triaging system, placing patients at risk.
In evidence the reasons given for the call handlers failure was that they did not know why she failed to escalate Mr Williams’ worsening condition and why she used the wrong algorithm and that the supplier of their IT software (the triage system), were reluctant to add a neurological algorithm , the reason for this is unclear. When asked the manager accepted that as the customer surely (the trust) could state that a neurological algorithm was necessary but merely that the supplier was reluctant.
It is unknown why the paramedic crew were unaware of the arranged admission bed and the manager accepted in evidence that he had not made any enquiries about this, prior to inquest. Again, this failure in communication is one which I feel places other patients at risk of death and is unacceptable. This is not an isolated incident (death) and it appears that there are system failures within your organisation which should be addressed.
” Source location Christopher Williams · Prevention of Future Deaths report
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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 Work with the IAED to improve triage standards and identify protocol gaps requiring clinical support.
Verbatim wording from the response “Emergency Call Handlers work using a triage system called Medical Priority Dispatch Solution (MPDS). This system is designed and owned by the International Academy of Emergency Dispatch (IAED).” Source location 2019-0183-Response-by-East-of-England-Ambulance-Service-NHS-Trust
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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 Meet the IAED, draft and submit a proposal for a neurological-deficit pathway in 999-call triage.
Verbatim wording from the response “We work with the IAED to improve standards of triage and to also identify where a protocol does not meet the needs of patients, whilst also understanding that in an emergency environment where 999 calls are triaged by non-clinicians there will be some calls which will need clinical support/intervention in reviewing the response. The Trust’s Audit and Training Manager will be shortly meeting the IAED’s UK Manager, following which the Trust will draft and submit a Proposal for Change (PFC) to the Academy asking that they identify a neurological deficit pathway which could be used in the triage of 999 calls.” Source location 2019-0183-Response-by-East-of-England-Ambulance-Service-NHS-Trust
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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 Send the neurological-deficit pathway proposal to NASMeD for consideration and support.
Verbatim wording from the response “We work with the IAED to improve standards of triage and to also identify where a protocol does not meet the needs of patients, whilst also understanding that in an emergency environment where 999 calls are triaged by non-clinicians there will be some calls which will need clinical support/intervention in reviewing the response. The Trust’s Audit and Training Manager will be shortly meeting the IAED’s UK Manager, following which the Trust will draft and submit a Proposal for Change (PFC) to the Academy asking that they identify a neurological deficit pathway which could be used in the triage of 999 calls.” Source location 2019-0183-Response-by-East-of-England-Ambulance-Service-NHS-Trust
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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 absence of a neurological-deficit protocol did not negatively affect the care provided or response assigned.
Verbatim wording from the response “In the case of Mr Williams, whilst there was no protocol which addresses neurological deficit, this had no negative detriment to the care provided or the response assigned by the AOC as the highest level of response was achieved (Category 1).” Source location 2019-0183-Response-by-East-of-England-Ambulance-Service-NHS-Trust
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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 IAED owns and designs the triage system, so protocol changes require its consideration and approval.
Verbatim wording from the response “Emergency Call Handlers work using a triage system called Medical Priority Dispatch Solution (MPDS). This system is designed and owned by the International Academy of Emergency Dispatch (IAED).” Source location 2019-0183-Response-by-East-of-England-Ambulance-Service-NHS-Trust
Open published response
2 May 2019 Alexander James Davidson · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 2
Failure to adapt NHS 111 telephone triage questions and wording for young and vulnerable patients View source Unclear NHS Pathways algorithm for exploring ‘soil’ or ‘coffee ground’ vomit during telephone triage View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
NHS England
Review the vomiting question to address callers’ unfamiliarity with the term “coffee-grounds”.
View source
NHS England
Add “soil” to the supporting information for the question about vomiting blood.
View source
NHS England
Review the gastrointestinal pathways, including diarrhoea and vomiting, clinical evidence on haematemesis, and whether user research could improve triage questions.
View source
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AI-generated summary
Alexander James 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
Alexander James Davidson became suddenly unwell with abdominal pain, vomiting and diarrhoea, and died at the Queens Medical Centre on 26 February 2018 after developing an infected and necrotic pancreatic pseudocyst caused by gallstone pancreatitis. The report raised concerns about NHS 111 telephone triage for young or vulnerable patients, the clarity and transfer of triage information, testing for pancreatitis in young people, and the management of unscheduled returns to emergency departments.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to adapt NHS 111 telephone triage questions and wording for young and vulnerable patients
Wider context from the report “(1) The NHS 111 telephone triage service uses the NHS Pathways computer system to triage patients via pre-determined question/answer based algorithms. The pre-determined questions are the same whether the caller is an adult or a child. Alex struggled to comprehend some of the medical terminology used during these calls. Call handlers are not permitted to deviate from the prescribed wording of the pre-determined questions, and this created confusion and inconsistency in the patient’s answers. Consideration should be given as to how young and/or vulnerable patients can be assisted to provide accurate information about their symptoms.
” Source location Alexander James Davidson · Prevention of Future Deaths report
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 Unclear NHS Pathways algorithm for exploring ‘soil’ or ‘coffee ground’ vomit during telephone triage
Wider context from the report “(2) The NHS Pathways algorithm for triaging vomiting and diarrhoea symptoms is unclear as patients may fail to understand what is meant by ‘soil’ or ‘coffee ground’ vomit . Consideration should be given to how this important diagnostic feature can be explored during telephone triage, especially when the patient is young and/or vulnerable.
” Source location Alexander James Davidson · Prevention of Future Deaths report
Open source report
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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 vomiting question to address callers’ unfamiliarity with the term “coffee-grounds”.
Verbatim wording from the response “In 2018 NHS Pathways reviewed the question that asks about dark brown or black vomit in view of the concern that callers may not be familiar with the term ‘coffee-grounds’. Removing the 'coffee-grounds' description could result in over referral as dark/black fluid alone without texture ('bits') could be drinks (e.g. cola, coffee, Guinness) or other dietary intake that has been vomited. The reference to coffee-grounds is a texture that is reasonably specific to haematemesis and this is commonly used in health-related literature, whereas cola is not. NHS.uk also refer to coffee-ground appearance only.” Source location 2019-0149-Response-by-NHS-Digital
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add “soil” to the supporting information for the question about vomiting blood.
Verbatim wording from the response “In 2016 NHS Pathways added reference to ‘soil’ in the ‘supporting information’ of the question asking about vomiting blood.” Source location 2019-0149-Response-by-NHS-Digital
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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 gastrointestinal pathways, including diarrhoea and vomiting, clinical evidence on haematemesis, and whether user research could improve triage questions.
Verbatim wording from the response “NHS Pathways are, as part of routine review and governance procedures, conducting a review of the gastrointestinal suite of pathways (including the diarrhoea and vomiting pathways), with changes planned for Release 19 (which will be deployed May 2020). As part of this review, the clinical evidence related to haematemesis will be reviewed with consideration also given as to whether user research will be helpful in improving triage questions and the identification of haematemesis.” Source location 2019-0149-Response-by-NHS-Digital
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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 Communication training, monthly audits, adaptable questioning and clinician transfer routes provide sufficient support for young or vulnerable callers.
Verbatim wording from the response “Call handlers are permitted to deviate from the exact wording presented by the system to a certain extent as each question has supplementary text called ‘supporting information’; the purpose of which is to guide the call handler to form additional probing questions or alternative ways of phrasing a question if a patient/caller might not understand what’s being asked.” Source location 2019-0149-Response-by-NHS-Digital
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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 coffee-ground description is clinically specific and supported by explanatory text; removing it could cause inappropriate over-referral.
Verbatim wording from the response “The question (see example below) currently asks whether there has been ‘dark brown or black vomit, like coffee-grounds’.” Source location 2019-0149-Response-by-NHS-Digital
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24 Jan 2019 Mr Viswambaran · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to provide reliable telephone access to the IAPT team for initial triage View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mr Viswambaran · 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
Mr Viswambaran, aged 27, was found dead at home on 18 September 2018 after overdosing on co-dydramol tablets. The report raises concerns about lengthy waiting times for IAPT therapy and difficulties contacting the IAPT service, which could contribute to deterioration or disengagement from mental health support.
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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 reliable telephone access to the IAPT team for initial triage
Wider context from the report “2) Mr Viswambaran had problems making contact with the IAPT team by telephone in order to arrange the initial triage telephone call . I am concerned that this may discourage people from pursuing assistance from the service .
” Source location Mr Viswambaran · Prevention of Future Deaths report
Open source report
9 Jan 2019 Diana Faith Gudgeon · Prevention of Future Deaths report Northamptonshire
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Concerns raised 2
Lower priority allocation by the ‘111’ Pathway triaging system than by the ‘999’ AMPDS system View source Failure of ‘111’ and EMAS call handling systems to treat neurological signs as urgent View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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Diana Faith Gudgeon · 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
Diana Faith Gudgeon collapsed at home after being diagnosed with a water infection and remained on the floor for a prolonged period. Her call was assessed as requiring a category three response, and substantial delays followed before ambulance attendance, hospital admission and treatment; she died on 25 May 2018 despite treatment for infection and sepsis. The principal concerns were the triage and escalation of her call, shortages of ambulance resources, and the effectiveness of EMAS capacity management arrangements.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lower priority allocation by the ‘111’ Pathway triaging system than by the ‘999’ AMPDS system
Wider context from the report “2. It was suggested in evidence that if the same facts are inputted into the ‘999’ AMPDS triaging system they are likely to allocate a higher priority to the call than the ‘111’ Pathway triaging system would .
” Source location Diana Faith Gudgeon · Prevention of Future Deaths report
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 of ‘111’ and EMAS call handling systems to treat neurological signs as urgent
Wider context from the report “1. Triaging by ‘111’ and EMAS call handling systems, including in relation to sepsis. In the present case, Mrs Gudgeon had collapsed, passed out, been confused and had been vomiting. These are signs of central nervous system/neurological problems but were not regarded as urgent. Despite EMAS being told that Mrs Gudgeon may have a urinary tract infection, no escalation occurred.
” Source location Diana Faith Gudgeon · Prevention of Future Deaths report
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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 Share concerns about NHS Pathways’ ability to identify possible sepsis with the software developers.
Verbatim wording from the response “Over the last year we have shared our concerns regarding NHS Pathways ability to pick up possible sepsis effectively and have fed our concerns back to them. This has resulted in changes to NHS Pathways in both versions 15 and 16. We have taken this call through NHS Pathways version 16 to try to identify the likely outcome had this version been in place at the time of the call. In version 16 the severely ill and new marks question has changed significantly. Firstly the 2 parts have now been split into separate questions. Due to concerns that the severely ill part of the question was too subjective this has been altered to “so ill they have stopped doing all normal activities”. The new marks part of the question is separate and triggered by answering the so ill they have stopped doing all normal activities question positively. The wording of the new marks part is unchanged.” Source location 2019-0015-Response-by-111-East-Midlands-CIC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The triage systems would not have warranted a Category 2 ambulance without both severe illness and new marks being present.
Verbatim wording from the response “The call has been reviewed against NHS Pathways version 14, which was in use at the time of the call. The key question relates to whether the patient was severely ill. The response from the son was unclear in answering this question. The Health Advisor (who is trained in the use of NHS Pathways, but who is not a clinician) could have probed this question more appropriately by utilising the supporting clarification information within NHS Pathways in order to get a clearer answer to this question. However, in order for this question to have been answered positively there is a second part to the question which asks whether the patient has new marks like bruising or bleeding under the skin. Both severely ill and the new marks have to be present in order for this question to be answered positively.” Source location 2019-0015-Response-by-111-East-Midlands-CIC
Open published response
28 Dec 2018 Mr Gregory Rekowski · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Mental-health telephone triage by staff with insufficient mental-health training View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Mr Gregory Rekowski · 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
Mr Gregory Rekowski was detained under the Mental Health Act after being found trying to tie a ligature, discharged from hospital, and later posted “last goodbyes” on social media. He was found hanging at his home on 29 October 2017. The report identified concerns about delays, communication breakdowns, unclear responsibilities and procedures among Pennine Care NHS Trust, Greater Manchester Police and North West Ambulance Service, including the lack of a face-to-face assessment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Mental-health telephone triage by staff with insufficient mental-health training
Wider context from the report “The decision to remove the concern for welfare call from the allocation list to be triaged by Urgent care meant no face to face assessment was conducted. Moreover the telephone triage call was conducted by a RGN who had limited mental health training .
” Source location Mr Gregory Rekowski · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a 24/7 control-room triage service staffed by mental health professionals alongside police communications staff.
Verbatim wording from the response “Control Room Triage
In 2017 North West Boroughs Healthcare NHS Foundation Trust were commissioned to deliver a pilot control room triage (CRT) service in partnership with Greater Manchester Mental Health, Pennine Care NHS Foundation Trust and GMP. This followed a successful business case for an initial 18-month pilot during which two mental health professionals would work alongside GMP staff within the Operational Communications Branch (OCB) 24/7, supporting the police and existing frontline services’ response to mental health demand within GMP calls.” Source location 2018-0411-Response-by-Greater-Manchester-Police
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12 Sep 2018 Greg HUTCHINS · Prevention of Future Deaths report Warwickshire
View report summary
Concerns raised 5
Failure to retain staff recollection of telephone triage View source Lack of contemporaneous records of telephone triage View source Failure to update the RIO system with telephone triage information View source
Lack of subsequent notes of telephone triage View source Lack of clarity about the purpose and scope of telephone triage View source See 2 more concerns
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Greg HUTCHINS · 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
Greg HUTCHINS committed suicide on 28 August 2017 in a hotel room after suffocating himself with a plastic bag and helium. Concerns included the lack of recollection and contemporaneous or subsequent records of a telephone triage, no update in the RIO system, uncertainty about the triage’s purpose, and limited rapid information sharing for people from outside the Birmingham area.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to retain staff recollection of telephone triage
Wider context from the report “(1) the staff member who conducted the telephone triage had no recollection of the triage whatsoever
(2) no contemporaneous of the triage were made
(3) no subsequent notes were made of the triage
(4) no update regarding the triage was made in RIO system
(5) the purpose of the telephone triage was unclear – it was described as not being a mental health assessment
(6) Mr Hutchins was from outside the Birmingham area and I heard evidence that no national system exists for rapid information sharing
” Source location Greg HUTCHINS · Prevention of Future Deaths report
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 Lack of contemporaneous records of telephone triage
Wider context from the report “(1) the staff member who conducted the telephone triage had no recollection of the triage whatsoever
(2) no contemporaneous of the triage were made
(3) no subsequent notes were made of the triage
(4) no update regarding the triage was made in RIO system
(5) the purpose of the telephone triage was unclear – it was described as not being a mental health assessment
(6) Mr Hutchins was from outside the Birmingham area and I heard evidence that no national system exists for rapid information sharing
” Source location Greg HUTCHINS · Prevention of Future Deaths report
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 update the RIO system with telephone triage information
Wider context from the report “(1) the staff member who conducted the telephone triage had no recollection of the triage whatsoever
(2) no contemporaneous of the triage were made
(3) no subsequent notes were made of the triage
(4) no update regarding the triage was made in RIO system
(5) the purpose of the telephone triage was unclear – it was described as not being a mental health assessment
(6) Mr Hutchins was from outside the Birmingham area and I heard evidence that no national system exists for rapid information sharing
” Source location Greg HUTCHINS · Prevention of Future Deaths report
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 Lack of subsequent notes of telephone triage
Wider context from the report “(1) the staff member who conducted the telephone triage had no recollection of the triage whatsoever
(2) no contemporaneous of the triage were made
(3) no subsequent notes were made of the triage
(4) no update regarding the triage was made in RIO system
(5) the purpose of the telephone triage was unclear – it was described as not being a mental health assessment
(6) Mr Hutchins was from outside the Birmingham area and I heard evidence that no national system exists for rapid information sharing
” Source location Greg HUTCHINS · Prevention of Future Deaths report
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 Lack of clarity about the purpose and scope of telephone triage
Wider context from the report “(1) the staff member who conducted the telephone triage had no recollection of the triage whatsoever
(2) no contemporaneous of the triage were made
(3) no subsequent notes were made of the triage
(4) no update regarding the triage was made in RIO system
(5) the purpose of the telephone triage was unclear – it was described as not being a mental health assessment
(6) Mr Hutchins was from outside the Birmingham area and I heard evidence that no national system exists for rapid information sharing
” Source location Greg HUTCHINS · Prevention of Future Deaths report
Open source report
3 Sep 2018 Andrew Arthur Dickson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure of the practice information system to reliably communicate telephone triage information to the subsequent face-to-face clinician View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
Stockport Medical Group
Record reception and triage information in patients’ clinical notes using the EMIS triage template.
View source
Stockport Medical Group
Train reception supervisors to use the new EMIS triage template.
View source
Stockport Medical Group
Have reception supervisors train staff across all three sites to use the EMIS triage template as the standard booking format.
View source
Stockport Medical Group
Request EMIS software changes to automate transfer of triage information into clinical notes.
View source
Stockport Medical Group
Adhere to the policy of recording reception and triage information in clinical notes pending suitable EMIS software adaptation.
View source See 2 more actions
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AI-generated summary
Andrew Arthur Dickson · 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
Andrew Arthur Dickson died on 15 February 2018, aged 30, after sustaining fatal injuries by jumping from a viaduct; the inquest recorded a conclusion of suicide. The report raised concerns that information about his suicidal thoughts, provided to the GP practice by telephone, was not incorporated into the screen seen by the doctor conducting the subsequent face-to-face consultation. It identified potential risks where information depends on clinician memory or on a patient or representative repeating it, particularly in group practices and for vulnerable or reluctant patients.
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× 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 practice information system to reliably communicate telephone triage information to the subsequent face-to-face clinician
Wider context from the report “Notwithstanding the obvious significance of the information provided to the practice by telephone on 12th February 2018 when an appointment with a GP was sought on the basis that Mr Dickson had been having suicidal thoughts, the evidence before the court was that whilst this information is made available to the telephone triage doctor by way of alert note, the same text is not incorporated in to the screen which a doctor subsequently undertaking a face-to-face appointment sees .
This raises the following matters of concern:-
1. The safety of the computer system as currently operated appears to be prefaced on the telephone triage doctor being the same clinician who sees the patient at a subsequent face-to-face consultation, and remembering the content of the alert note despite having had to undertake a multitude of other tasks in the meantime ;
2. In the alternative, the onus is likely to fall on the patient (or his / her representative or carer) to repeat information in the course of the consultation which may already be in the practice’s knowledge as a result of an earlier telephone call to an administrative member of staff , and which the patient (carer or representative) is likely to assume is already in the doctor’s possession;
3. The system as currently operated appears likely to create additional risk in a group practice (in circumstances where the telephone triage doctor may be based in a different location from the doctor undertaking a subsequent consultation), and where patients may be vulnerable or reluctant to engage with a doctor for any reason.
” Source location Andrew Arthur Dickson · Prevention of Future Deaths report
Open source report
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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 Record reception and triage information in patients’ clinical notes using the EMIS triage template.
Verbatim wording from the response “The partners’ discussion centred around the need to achieve a balance between the need for all pertinent clinical information to be visible in the clinical records on the one hand, and the need to avoid unnecessary or administrative entries that can clog up the notes and may potentially make it more difficult for a clinician to be able to identify relevant clinical information. We decided that it would be unreasonable and potentially unsafe to expect staff taking these calls, who are not medically trained, to decide what information is clinically relevant. It was therefore agreed that the practice should adopt a policy that all information recorded by reception staff from patients or carers’ initial calls, along with any subsequent notes made by the triage doctor, should be recorded in the clinical notes. These notes are available for clinicians to consult across all practice locations.” Source location 2018-0296-Response-by-Stockport-Medical-Group
Open published response
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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 Train reception supervisors to use the new EMIS triage template.
Verbatim wording from the response “We have organised training with the reception supervisors in order to ensure that this new EMIS template is being used whenever patients are booked onto the triage list. This training is scheduled to take place over the next 4 weeks. Our reception supervisors will subsequently inform and train staff at each of our 3 sites, explaining that this is now the standard format for adding patients onto the triage list. We therefore expect that all notes will now appear on the EMIS clinical records.” Source location 2018-0296-Response-by-Stockport-Medical-Group
Open published response
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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 Have reception supervisors train staff across all three sites to use the EMIS triage template as the standard booking format.
Verbatim wording from the response “We have organised training with the reception supervisors in order to ensure that this new EMIS template is being used whenever patients are booked onto the triage list. This training is scheduled to take place over the next 4 weeks. Our reception supervisors will subsequently inform and train staff at each of our 3 sites, explaining that this is now the standard format for adding patients onto the triage list. We therefore expect that all notes will now appear on the EMIS clinical records.” Source location 2018-0296-Response-by-Stockport-Medical-Group
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 Request EMIS software changes to automate transfer of triage information into clinical notes.
Verbatim wording from the response “Our practice currently uses the EMIS Web clinical system which is used nationally. This system does not currently have the means to automatically pull information across from triage or appointment slots into the clinical notes. We consider that it would be preferable for this to be automated, removing the manual part of the process outlined above. We have written to EMIS on 21st September 2018 (reference ECR 10381933) requesting this addition to their software. We have highlighted why there is a need for this and the potential implications of an omission of this software capability, as clearly outlined in your letter.” Source location 2018-0296-Response-by-Stockport-Medical-Group
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 Adhere to the policy of recording reception and triage information in clinical notes pending suitable EMIS software adaptation.
Verbatim wording from the response “The partners’ discussion centred around the need to achieve a balance between the need for all pertinent clinical information to be visible in the clinical records on the one hand, and the need to avoid unnecessary or administrative entries that can clog up the notes and may potentially make it more difficult for a clinician to be able to identify relevant clinical information. We decided that it would be unreasonable and potentially unsafe to expect staff taking these calls, who are not medically trained, to decide what information is clinically relevant. It was therefore agreed that the practice should adopt a policy that all information recorded by reception staff from patients or carers’ initial calls, along with any subsequent notes made by the triage doctor, should be recorded in the clinical notes. These notes are available for clinicians to consult across all practice locations.” Source location 2018-0296-Response-by-Stockport-Medical-Group
Open published response
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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 Automating transfer of triage information into clinical notes depends on EMIS adding the required software capability.
Verbatim wording from the response “Our practice currently uses the EMIS Web clinical system which is used nationally. This system does not currently have the means to automatically pull information across from triage or appointment slots into the clinical notes. We consider that it would be preferable for this to be automated, removing the manual part of the process outlined above. We have written to EMIS on 21st September 2018 (reference ECR 10381933) requesting this addition to their software. We have highlighted why there is a need for this and the potential implications of an omission of this software capability, as clearly outlined in your letter.” Source location 2018-0296-Response-by-Stockport-Medical-Group
Open published response
9 May 2018 Edward Joyce · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2
Failure to provide advice to return to hospital after reported high temperature following a burn View source Failure to record reported high temperature in telephone notes View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Edward Joyce · 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
Edward Joyce suffered an accidental scalding injury on 19 November 2017 and later developed septic shock from infected burns. He became severely unwell on 22 November and died despite attempts at resuscitation. Concerns included that a temperature of 38.9°C did not trigger an urgent hospital referral and was not recorded when his mother telephoned the hospital, and that parents were not advised to bring him back to hospital.
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× 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 advice to return to hospital after reported high temperature following a burn
Wider context from the report “The evidence at the inquest was that a temperature reading above 38°C following a burn to a young child is highly concerning, and could be an early sign of septicaemia and toxic shock syndrome.
(1) The temperature reading of 38.9°C at the GP did not trigger an urgent referral to hospital.
(2) Eddie’s mother was clear that she reported this temperature reading to the nurse at Chelsea & Westminster when she telephoned soon after the GP appointment. This reading is not recorded in the telephone note and the parents were not told to bring Eddie back to hospital .
(3) The evidence was that scalding injuries amongst children are very common but that toxic shock syndrome is very rare. In their evidence the hospital witnesses helpfully considered whether the information leaflet could be reviewed so as to assist other health professionals who may be less aware of the potential significance of high temperature following a burn and availability of a 24 hour telephone advice from the burns unit.
” Source location Edward Joyce · Prevention of Future Deaths report
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 record reported high temperature in telephone notes
Wider context from the report “The evidence at the inquest was that a temperature reading above 38°C following a burn to a young child is highly concerning, and could be an early sign of septicaemia and toxic shock syndrome.
(1) The temperature reading of 38.9°C at the GP did not trigger an urgent referral to hospital.
(2) Eddie’s mother was clear that she reported this temperature reading to the nurse at Chelsea & Westminster when she telephoned soon after the GP appointment. This reading is not recorded in the telephone note and the parents were not told to bring Eddie back to hospital.
(3) The evidence was that scalding injuries amongst children are very common but that toxic shock syndrome is very rare. In their evidence the hospital witnesses helpfully considered whether the information leaflet could be reviewed so as to assist other health professionals who may be less aware of the potential significance of high temperature following a burn and availability of a 24 hour telephone advice from the burns unit.
” Source location Edward Joyce · Prevention of Future Deaths report
Open source report
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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 Alert the Paediatric Burns Network to the advice so that improvements can be made more widely.
Verbatim wording from the response “With regard to the national information leaflet, it does set out the warning signs to look out for in a child who has sustained a burns injury and is developing sepsis or Toxic Shock Syndrome (TSS); I can confirm that the existing leaflet contains nationally accepted advice in attending to burns injuries in children. It also contains the correct symptoms (red flags) and the correct advice as to what parents ought to do if concerned, including where to seek further treatment and advice. We have also alerted the Paediatric Burns Network to your advice so that any improvements can be made more widely. We would also like to reassure you that our burns unit can already be contacted by telephone 24 hours every day.” Source location 2018-0142-Response-by-Chelsea-and-Westminster-Hospital-NHS-Trust
Open published response
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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 There was no suggestion that a temperature spike was mentioned during the telephone call and then not recorded or acted upon.
Verbatim wording from the response “It is the Trust’s understanding that the evidence from Nurse ████████ explained the action that would have been taken if a spike in temperature was mentioned during the relevant telephone call but there was no suggestion that a spike in temperature was mentioned and not recorded / acted on.” Source location 2018-0142-Response-by-Chelsea-and-Westminster-Hospital-NHS-Trust
Open published response
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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 existing national leaflet already provides nationally accepted burns advice, correct warning signs, and appropriate instructions for parents seeking further care.
Verbatim wording from the response “With regard to the national information leaflet, it does set out the warning signs to look out for in a child who has sustained a burns injury and is developing sepsis or Toxic Shock Syndrome (TSS); I can confirm that the existing leaflet contains nationally accepted advice in attending to burns injuries in children. It also contains the correct symptoms (red flags) and the correct advice as to what parents ought to do if concerned, including where to seek further treatment and advice. We have also alerted the Paediatric Burns Network to your advice so that any improvements can be made more widely. We would also like to reassure you that our burns unit can already be contacted by telephone 24 hours every day.” Source location 2018-0142-Response-by-Chelsea-and-Westminster-Hospital-NHS-Trust
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 burns unit can already be contacted by telephone 24 hours a day, every day.
Verbatim wording from the response “With regard to the national information leaflet, it does set out the warning signs to look out for in a child who has sustained a burns injury and is developing sepsis or Toxic Shock Syndrome (TSS); I can confirm that the existing leaflet contains nationally accepted advice in attending to burns injuries in children. It also contains the correct symptoms (red flags) and the correct advice as to what parents ought to do if concerned, including where to seek further treatment and advice. We have also alerted the Paediatric Burns Network to your advice so that any improvements can be made more widely. We would also like to reassure you that our burns unit can already be contacted by telephone 24 hours every day.” Source location 2018-0142-Response-by-Chelsea-and-Westminster-Hospital-NHS-Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.