20 Dec 2023 James CAMPION · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1
Delays in triaging emergency calls involving threats of overdose View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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James CAMPION · 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
James Campion, aged 57, died after consuming mirtazapine and alcohol following contact with the Psychiatric Crisis Team about taking an overdose. An ambulance was not allocated until six hours after the initial call, and he was found deceased at home when the crew arrived. The principal concerns were delays in mental health assessment, call triage and ambulance dispatch, alongside inadequate family contact information and limited family involvement.
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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 Delays in triaging emergency calls involving threats of overdose
Wider context from the report “The delay in triaging the call made by Mr Campion threatening to take an overdose resulted in him taking the overdose. The delay in the ambulance dispatch prevented Mr Campion receiving medical treatment and further psychiatric assistance. The outcome for Mr Campion has been adversely impacted due to the demand on the ambulance service . At the time of the 999 call on 21st July 2022 NWAS were operating at Level 4 of the Plan (PSP) experiencing high demand, acute pressures and high numbers of waiting calls. The options for the emergency services were extremely limited and an ambulance was deployed at the earliest opportunity. Consideration be given to how to support the Ambulance and Mental Health Services in fulfilling the NHS long-term plan for Mental Health, in particular Mental Health Practitioners in Ambulance control rooms.
” Source location James CAMPION · 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 Deploy mental health professionals in 999 call centres and clinical assessment services to direct people in crisis to appropriate care.
Verbatim wording from the response “To supplement this new NHS111 offer, we are also deploying mental health professionals in 999 call centres and clinical assessment services to help ensure that people experiencing a mental health crisis are directed towards appropriate services.” Source location Response from Department of Health and Social Care
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27 Feb 2023 Sharon Elizabeth Langley · Prevention of Future Deaths report Essex
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Concerns raised 1
Delays in calling emergency services and relaying basic emergency information View source
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
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Sharon Elizabeth Langley · Prevention of Future Deaths report
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Report summary
Sharon Elizabeth Langley, an inpatient with Severe Depressive Disorder and Psychosis, died by immersion in water while unsupervised in an assisted bathroom at Princess Alexandra Hospital on 10 August 2019. The principal concerns included failures in the immediate emergency response, inadequate communication and coordination, shortcomings in bathroom and high-risk-area safety measures, confusion about bath-plug controls, unreliable investigation and learning processes, and inadequate record keeping and risk documentation.
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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 Delays in calling emergency services and relaying basic emergency information
Wider context from the report “(1) Essex Partnership NHS Foundation Trust staff immediate emergency response was not followed:
a. pinpoint alarms were not activated immediately on finding Sharon Langley unresponsive
b. there was a delay calling the ambulance and basic key information about the type of the emergency was not relayed :
i. by qualified nurses who made the 999 calls , or
ii. to paramedics on attendance
c. there was a delay informing the site co-ordinator of the emergency even though she was based on the ward and there was a lack of co-ordination of the emergency resulting in the ambulance being called a second time by the site co-ordinator
d. staff trained in basic life support did not assist the two nurses who were attempting to resuscitate Sharon Langley
” Source location Sharon Elizabeth Langley · 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 Deliver drop-in refresher life-support training for clinical and administrative staff, emphasizing immediate help-seeking and pinpoint-alarm use.
Verbatim wording from the response “- EPUT’s Head of Deteriorating Patient Pathways and Resuscitation Training Officer is working closely with mental health wards to facilitate drop-in ‘refresher’ life support training for clinical and administrative staff dealing with emergency situations. During” Source location Response from Essex Partnership University NHS Foundation Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a medical-emergency simulation with Derwent Centre staff and share incident learning for incorporation into current training.
Verbatim wording from the response “- The issue of calling for help as soon as possible is also shared during the weekly ‘virtual’ drop-in sessions which focus on the deteriorating patient. Head of Deteriorating Patient Pathways and Resuscitation Training Officer will continue to work with staff at the Derwent Centre to conduct a medical emergency simulation with the team and the importance of calling for help at the earliest possible opportunity is relayed during the post simulation feedback. In addition, the Trust’s training team have shared details of the learning from this incident and request for incorporation and sharing within the current training programme (1b, 1c).” Source location Response from Essex Partnership University NHS Foundation Trust
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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 Develop and launch an emergency communication tool containing essential patient and site information for ambulance calls across all wards.
Verbatim wording from the response “- The Head of Deteriorating Patient Pathways and Resuscitation Training Officer, operational colleagues and the Lessons Team are formulating a communication tool for use when contacting the East of England Ambulance Service. EPUT Subject Matter Experts have liaised with external partner colleagues to devise the tool and the specific information which our colleagues will require in emergency scenarios. The questions the Ambulance control room will ask when reporting an emergency have been used as the basis for the communication tool poster. It will include essential information relating to the patients presenting medical condition, as well as site information including address and postcode. This aide memoir poster will be positioned adjacent to the Nurses Station and a laminated copy placed inside the grab bag. This is due to be completed and launched across all wards in May 2023 (1b).” Source location Response from Essex Partnership University NHS Foundation Trust
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Concerns raised 1
Failure to answer or respond to calls within adequate timeframes 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. 14
Devon & Cornwall Police
Run recruitment campaigns to increase CMCU staffing and stabilise retention.
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Devon & Cornwall Police
Regrade the RIMO role and increase its salary to support staff retention.
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Devon & Cornwall Police
Use NICHE and Single Online Home to improve contact processing and public service delivery.
View source
Devon & Cornwall Police
Introduce AACC7 to enable call-backs, a single voice queue and improved 101 answer times.
View source
Devon & Cornwall Police
Introduce leaner processes to clarify responsibility and reduce call and follow-up work.
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Devon & Cornwall Police
Analyse abandoned-call data to understand caller behaviour and contact-channel changes.
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Devon & Cornwall Police
Transfer some incoming-contact management from Contact to local BCUs to increase RIMO capacity for 999 calls.
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Devon & Cornwall Police
Provide dedicated Human Resources support for staff wellbeing, absence intervention, workplace adjustments and management effectiveness.
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Devon & Cornwall Police
Review shift patterns and move staffing towards peak-demand hours.
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Devon & Cornwall Police
Implement the agreed new shift pattern for contact handlers.
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Devon & Cornwall Police
Review identified Contact process improvements to improve service delivery.
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Devon & Cornwall Police
Streamline nine Contact processes, including processes for missing people, Claire’s Law, Sarah’s Law and domestic abuse.
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Devon & Cornwall Police
Operate a Demand Reduction team to identify repeat and vulnerable callers and reduce persistent or nuisance contact.
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Devon & Cornwall Police
Open six additional police-station front offices and train staff to handle digital and non-urgent contact.
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Daniel Lee Tilley · 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
Daniel Lee Tilley was found hanging in Newquay on 7 July 2019 and was later pronounced dead by paramedics. The report identifies concerns about insufficient police staffing and resources, including a four-hour response delay to an emergency call. The inquest concluded that it was possible the delay contributed to the outcome, although the evidence was insufficient to determine whether Daniel intended to take his own life.
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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 answer or respond to calls within adequate timeframes
Wider context from the report “ii. a) Staffing levels in the CMCUs (both call handlers and Resource Deployment Officers) in Plymouth and Exeter are insufficient for the workloads experienced.
b) There are an inadequate number of uniformed Officers available to respond in a timely fashion to the demand seen over the summer months.
Let me acknowledge that I recognise these two issues are intertwined. The amount of budget the force receives will dictate what it can afford in terms of police staff and police officers. As Chief Inspector ████████ accepted during the course of this inquest, the police did the best they could with what they had; they simply did not have enough.
My concern in relation to the CMCU is that this problem has existed – on the evidence I heard at inquest – for a decade or so, and it is unresolved today. I am bound to note the recent decision of HMICFRS to move the force into an enhanced level of monitoring with one of the stipulated grounds being: ‘the force does not answer, or respond to, emergency or non-emergency calls within adequate timeframes, and too many calls are abandoned… ’
The jury heard from Chief Supt ████████ and ACC Leaper at inquest. They were told that staffing levels for both call handlers and RDOs were still not at the ‘design’ brief advised by BT but that recruitment processes were in hand which, it was hoped, would achieve this. They were told that three separate pieces of software were to be introduced in the New Year which, once fully operational, ought to permit greater efficiencies and speedier call management.
In writing to you, I wanted to bring these matters to your attention so that you can ensure the intended improvements are realised. I understand once you start in your new role you will require a little time to bring yourself up to speed with what will inevitably be a raft of pressing issues, that budgets for 2022/3 are yet to be finalised and, finally, that the recruitment drive and IT upgrades still need to be completed. For those reasons, I have extended the time below for the formal Reply from you.
” Source location Daniel Lee Tilley · 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 Run recruitment campaigns to increase CMCU staffing and stabilise retention.
Verbatim wording from the response “As of January 2023, we have 138 Radio Dispatch Officers (now called Resource Incident Management Officers (RIMOs)) against a design of 143 and 191 Contact Officers against a design of 194, which represents an increase in staffing levels since the inquest. These staffing levels were identified by reference to a review by BT, an independent consultant who examined our processes and staffing numbers (as previously shared in the inquest).” Source location Response from Devon & Cornwall Police
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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 Regrade the RIMO role and increase its salary to support staff retention.
Verbatim wording from the response “In addition, the RIMO role has been regraded through a job evaluation process and a salary increase awarded which we anticipate will assist with retention. During exit interviews upon leaving the organisation, our outgoing staff have previously raised the issue of pay as one of the reasons for leaving the police.” Source location Response from Devon & Cornwall Police
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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 Use NICHE and Single Online Home to improve contact processing and public service delivery.
Verbatim wording from the response “New software and technological changes” Source location Response from Devon & Cornwall Police
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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 Introduce AACC7 to enable call-backs, a single voice queue and improved 101 answer times.
Verbatim wording from the response “New software and technological changes” Source location Response from Devon & Cornwall Police
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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 Introduce leaner processes to clarify responsibility and reduce call and follow-up work.
Verbatim wording from the response “In addition, we have been introducing leaner processes to improve clarity of responsibility in turn leading to less time spent on calls and follow up work.” Source location Response from Devon & Cornwall Police
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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 Analyse abandoned-call data to understand caller behaviour and contact-channel changes.
Verbatim wording from the response “• The force is working to understand the data behind abandoned calls; for example, whether abandoned calls represent the public abandoning calls altogether, or whether they represent the public moving to a different method of contact that provides a quicker response (such as a 101 call or web chat).” Source location Response from Devon & Cornwall Police
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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 Transfer some incoming-contact management from Contact to local BCUs to increase RIMO capacity for 999 calls.
Verbatim wording from the response “• Some management of incoming contact from the public has moved from Contact to local basic command units (BCUs – basically, local policing areas) to free up RIMO time to take 999 calls.” Source location Response from Devon & Cornwall Police
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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 Provide dedicated Human Resources support for staff wellbeing, absence intervention, workplace adjustments and management effectiveness.
Verbatim wording from the response “• We have increased our focus on maximising the wellbeing of our staff and the support offered to them. We have dedicated Human Resources provision in place to provide enhanced support for individuals through: effective people management; increasing effectiveness of early interventions for absences to avoid unnecessary escalation; effective and timely use of workplace adjustments; empower and increase the confidence of our managers; and potentially an increase in informal performance management processes should managers not undertake their responsibilities effectively. This is with the overall aim of improving performance and retention and thus contribute to an improved service to our communities. Since the introduction of this team in October 2022 sickness levels have reduced from 15% absence rate to 11% in January 2023.” Source location Response from Devon & Cornwall Police
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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 Review shift patterns and move staffing towards peak-demand hours.
Verbatim wording from the response “• We have also reviewed (and will continue to review) the shift patterns to ensure we have more staff working in peak demand hours. In particular, the Incident Resolution Centre (IRC) moved to a new shift pattern as of January 2023. The IRC role is one of managing demand; the team undertakes crime-related tasks and crime screening, with the effect of reducing repeat calls to the organisation and the early resolution of complaints, allegations, and incidents. A new shift pattern has also been agreed for contact handlers and will be implemented in line with the Police Staff Handbook, which we anticipate being implemented in July 2023.” Source location Response from Devon & Cornwall Police
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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 Implement the agreed new shift pattern for contact handlers.
Verbatim wording from the response “• We have also reviewed (and will continue to review) the shift patterns to ensure we have more staff working in peak demand hours. In particular, the Incident Resolution Centre (IRC) moved to a new shift pattern as of January 2023. The IRC role is one of managing demand; the team undertakes crime-related tasks and crime screening, with the effect of reducing repeat calls to the organisation and the early resolution of complaints, allegations, and incidents. A new shift pattern has also been agreed for contact handlers and will be implemented in line with the Police Staff Handbook, which we anticipate being implemented in July 2023.” Source location Response from Devon & Cornwall Police
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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 Review identified Contact process improvements to improve service delivery.
Verbatim wording from the response “• An independent review was carried out in September 2022 by Sopra Steria, who are an external technological consultant. The purpose of this work was to review Contact processes so the force could become more efficient, to better utilise resources and enable people to work more effectively, therefore providing a better quality of service to the public across different methods of contact (for example: 999, 101, email and webchat). Sopra Steria identified process improvements which are now being reviewed with a view to improve our service delivery. These external consultants provided support to understand, by reference to the wider call centre industry, what further process improvements and areas of development should be pursued alongside our ongoing work in this area.” Source location Response from Devon & Cornwall Police
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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 Streamline nine Contact processes, including processes for missing people, Claire’s Law, Sarah’s Law and domestic abuse.
Verbatim wording from the response “Since that work was carried out, process reviews have been undertaken concentrating on areas such as missing people, requests made by the public under Claire’s Law and Sarah’s Law, and domestic abuse. This resulted in nine of our processes being streamlined to improve public service.” Source location Response from Devon & Cornwall Police
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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 Demand Reduction team to identify repeat and vulnerable callers and reduce persistent or nuisance contact.
Verbatim wording from the response “• We introduced a Demand Reduction team to identify repeat and vulnerable callers. In addition, this looks to reduce contact from persistent / nuisance callers, utilising partnership work, civil orders, and prosecution where appropriate to reduce this demand. We have seen a similar issue occur with digital contact: for example, one member of the public with mental health issues emailed the force 3,000 times in August. We now have processes in place to help reduce the demand caused by persistent / nuisance emailers.” Source location Response from Devon & Cornwall Police
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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 Open six additional police-station front offices and train staff to handle digital and non-urgent contact.
Verbatim wording from the response “• Finally, we opened an additional six front offices in our police stations in January 2023 (in Tiverton, Truro, Falmouth, Penzance, Newton Abbot and Bude) increasing the provision of front office services. This enables a better service to the public by providing greater connectivity and accessibility. The front office staff will be trained to deal with digital demand and non-urgent contact demand, supported by new technology, significantly expanding the available resource base for Contact.” Source location Response from Devon & Cornwall Police
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25 Nov 2022 Philip John BATTLE · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1
Failure of ambulance triage to identify a person who could check the caller’s safety View source
This report raised 3 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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Philip John BATTLE · 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
Philip John Battle died by suicide on 8 July 2022 after contacting the ambulance service about an overdose and an attempted hanging. The report raised concerns that the ambulance triage process focused on physical health rather than immediate mental-health and self-harm risks, and that no attempt was made to contact someone who could check on his safety. It also identified limited coordination and shared mental-health crisis resources between ambulance, police and health services.
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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 ambulance triage to identify a person who could check the caller’s safety
Wider context from the report “Evidence has been received that Philip Battle self-referred to the ambulance service stating he had taken an overdose and that he had tried to hang himself. The then triage system (medical priority dispatch) concentrated on questions relating to physical health such as his physiological function rather than assessing the actual presenting risks from poor mental health including self-inflicted fatal harm. Mr Battle lived in warden monitored sheltered accommodation and no inquiry was made about whether someone could be telephoned to check on his safety . Even if Mr Battle had not been in sheltered accommodation, it was unclear as to why there was no triage question about a phone number for a friend or relative . Evidence was given that NWAS work with Lancashire police and the health service in Blackpool with the Synergy project sharing the resources of a triage mental health car. These arrangements and relationships do not exist in Liverpool. The Court was concerned about silo - public health working between Blue light services - given the limited mental health intervention resource for NWAS was not on duty on the morning of 8th July and there was no call to Merseyside Police to see if its Mental Health triage car was available to intervene. Evidence was heard that these services need commissioning and there was no arrangement between Merseyside Police and the NWAS to share mental health intervention resources. This issue appears to become more important when the court heard of the plans for three mental health ambulances to be available in Merseyside and Cheshire in the near future.
The Court would like the ambulance service, Police and health providers to work together with the public funds at their respective disposal to develop in concert and to share community mental health crisis intervention resources for the good of the public.
” Source location Philip John BATTLE · Prevention of Future Deaths report
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4 Nov 2022 Levi Louis Alleyne · Prevention of Future Deaths report Berkshire
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Concerns raised 1
Fragmented DNO emergency contact arrangements across ambulance service boundaries View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Levi Louis Alleyne · 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
Levi Louis Alleyne, a grab lorry delivery driver, died by electrocution at a building site after raising his lorry’s crane arm beneath overhead power lines. CPR was delayed because it was unclear whether the electricity remained live, and the ambulance control operator had no procedure or readily accessible emergency contact information for the relevant electricity network operator. The report identifies risks of delayed life-saving treatment or people approaching live electrical hazards and notes that similar mitigating procedures may not be adopted across England and Wales.
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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 Fragmented DNO emergency contact arrangements across ambulance service boundaries
Wider context from the report “According to the evidence heard at the inquest:
1. At the time of the incident, the SCAS operator did not have any instruction in their Standard Operating Procedure to contact the local [DNO] to ensure that the electricity was cut off. There is no such instruction in the national Standard Operating Procedure.
2. The SCAS operator did identify and try to contact the DNO after the 999 call had ended. However, as they did not contact the correct emergency number provided by SSEN, they were kept on hold for several minutes. The emergency numbers are not incorporated into the software used by the ambulance control centre (CAD) and are not widely known.
3. There is considerable potential for confusion for ambulance control centres as there is not one national DNO emergency number to contact . There are 14 licensed DNOs and 12 ambulance service trusts in England and Wales with different boundaries . Ambulance control centres frequently pick up calls from other ambulance trust areas at times of high demand . The ambulance control centre must find the relevant DNO to contact and the relevant number for that DNO .
4. There was a delay in Mr Alleyne receiving CPR due to concerns about electricity still being live. There are thousands of incidents every day involving OHPLs. There is a risk that future deaths may occur due to confusion regarding electrical hazards.
5. The potential for future deaths is two-fold:
▪ unnecessary delay to life-saving treatment being given due to the fear (well-founded or otherwise) that OHPLs are still live,
▪ or potentially, by-standers or emergency services putting their lives at risk by approaching patients near electrical hazards where OHPLs remain live.
” Source location Levi Louis Alleyne · 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 Share updated ambulance-service SOPs, including electricity-network maps and distribution-network-operator contact details, across NHS ambulance services.
Verbatim wording from the response “I can confirm that actions taken by South Central Ambulance Service NHS Trust, to update their Standard Operating Procedures (SOPs) following the inquest, have been shared across all NHS ambulance services, including a map and the appropriate contact details for each of the electricity Distribution Network Operators. In addition, to reinforce the required steps, the matter is being discussed with all Heads of Emergency Operations Centres at their meeting in January 2023.” Source location Response from AACE
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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 Complete a review with each DNO and TNO confirming effective annual communication of regional network boundaries to local emergency services.
Verbatim wording from the response “ENA has asked each DNO and TNO to check and confirm that suitable and effective arrangements are in place to regularly communicate on an annual basis, their overall network boundaries at a regional level or equivalent with their local emergency services. This will help maintain awareness of the appropriate DNO and TNO to be contacted in the event of an emergency involving overhead powerlines (OHPLs).” Source location Response from Energy Networks Association
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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 membership organisation can provide guidance and collaboration but cannot mandate NHS ambulance services to implement safety action.
Verbatim wording from the response “Please note, AACE is a membership organisation, subscribed to by all UK NHS ambulance services, and as such can offer guidance, encourage collaboration across services, and represent sector views, but cannot mandate action.” Source location Response from AACE
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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 Preparing or overseeing local or national standard operating procedures and nationally overseeing 111 or 999 operations fall outside NHS Pathways’ remit.
Verbatim wording from the response “NHS Pathways remit does not extend to preparing or overseeing local or national standard operating procedures or providing national oversight of 111 or 999 operations. Standard operating procedures relating to a range of operational requirements are locally set by 111 and 999 providers. NHS Pathways is a clinical decision support system and more operationally focused content such as how to contact a utility provider sits outside the remit of the NHS Pathways system.” Source location Response from NHS Digital
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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 Distribution and transmission network operators have suitable and effective arrangements with local emergency services for incidents involving electricity-network equipment.
Verbatim wording from the response “We have contacted the Energy Networks Association (ENA), who have advised that DNOs and Transmission Network Operators (TNO) have suitable and effective arrangements in place with their local emergency services providers. This includes ensuring that emergency services have suitable emergency contact details for their DNO and that they know how to respond to an incident involving equipment on the electricity network. In future, the ENA has requested that DNOs and TNOs check their arrangements with the emergency services on an annual basis.” Source location Response from Health and Safety Executive
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4 Oct 2022 Reginald Cauthery · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Failure to answer telecare fire calls as a priority View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Reginald Cauthery · 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
Reginald Cauthery was a frail man with limited mobility who lived alone and died in hospital after sustaining extensive burns in a smouldering fire at his flat. The report raised concerns that his telecare service was not reviewed despite his increased fire risk and deteriorating mobility, and that his smoke alarms were not connected to the telecare system, delaying contact with the Fire Brigade.
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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 answer telecare fire calls as a priority
Wider context from the report “(3) If Mr Cauthery’s smoke alarm had been connected to his telecare system, the call would have been answered as a priority . In addition, the call handler would not have spent several minutes seeking confirmation that the smoke alarm was going off before making a 999 call.
” Source location Reginald Cauthery · 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 Commence development of a Fire Call Handling Pathway Decision Support Tool after completing the Ambulance tool, with NFCC and LFB support if available.
Verbatim wording from the response “Once our work on the Ambulance Pathway Decision Support Tool is complete, we will commence work on a similar tool for Fire Call Handling, with the support of NFCC and LFB if they are willing to do so. It must be recognised that it is likely that such a tool would not be available for use by service providers” Source location Response from TEC Services Association
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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 Telecare and fire-service matters fall outside regulation, leaving no powers to prevent future deaths concerning those services.
Verbatim wording from the response “However, the matters of concerns highlighted in the Regulation 28 report relate to services outside our scope of regulation. We do not regulate the fire service or the” Source location Response from Home Care Quality Commission
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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 investigation found no evidence that involved TEC services were specifically at fault, while identifying disjointed agency working as significant.
Verbatim wording from the response “On this occasion and from our discussions, we could not see any evidence that the TEC services involved, were at fault in any specific way, but we do feel that the disjointed way of working between agencies is a significant factor in this case. However, we do believe that lessons can be learnt.” Source location Response from TEC Services Association
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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 A Fire Call Handling Pathway Decision Support Tool is unlikely to be available until 2024 because development, testing, training and evaluation are required.
Verbatim wording from the response “Once our work on the Ambulance Pathway Decision Support Tool is complete, we will commence work on a similar tool for Fire Call Handling, with the support of NFCC and LFB if they are willing to do so. It must be recognised that it is likely that such a tool would not be available for use by service providers” Source location Response from TEC Services Association
Open published response
15 Jun 2022 Keith Hopwood · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to automatically escalate disconnected ambulance calls from callers who are alone View source
This report raised 3 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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AI-generated summary
Keith Hopwood · 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
Keith Hopwood fainted and felt very unwell before calling an ambulance, reporting chest pain during a later call. He was found unresponsive at home and could not be resuscitated; the medical cause of death was myocardial infarction due to stenotic coronary artery atheroma. The concerns included delays and resource pressures in the ambulance service, failure to upgrade the call category, limitations in the call-handling algorithm, the use of a private ambulance not equipped to deal with a cardiac patient, and the handling of a disconnected call when he was alone.
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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 automatically escalate disconnected ambulance calls from callers who are alone
Wider context from the report “4. The second call from Mr Hopwood disconnected. Because he was alone a disconnection does not automatically result in an escalation of a call . Had he been with someone who said he had become unresponsive that would have generated a different approach.
” Source location Keith Hopwood · Prevention of Future Deaths report
Open source report
7 Mar 2022 Josephine Celia BARKER · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Failure to make callbacks after dropped calls and at the two-hour mark View source
This report raised 13 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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AI-generated summary
Josephine Celia BARKER · 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
Josephine Celia Barker suffered an unwitnessed fall and serious head injury in an Aldi car park on 15 February 2019. She waited over two hours for an ambulance after five 999 calls, and later died from her injuries on 3 March 2019. The principal concerns included inadequate triage and re-triage, failure to use clinical information from paramedics at the scene, lack of callbacks and clinical review, and the diversion of an allocated ambulance to a welfare briefing.
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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 make callbacks after dropped calls and at the two-hour mark
Wider context from the report “7. There were no callbacks made either to the caller whose call was dropped or to any of the callers at the 2 hour mark .
” Source location Josephine Celia BARKER · Prevention of Future Deaths report
Open source report
4 Feb 2022 Sarah Marie GILBERT-JONES · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Failure of call-processing protocols to incorporate overdose information into response categorisation View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Sarah Marie GILBERT-JONES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sarah Marie GILBERT-JONES died in the early hours of 29 October 2020 after taking a significant overdose of prescription medication with alcohol. The report raised concerns about delays and inconsistent categorisation in the emergency response, including failure to recognise that treatment was time critical, and about sub-optimal mental health service provision.
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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 call-processing protocols to incorporate overdose information into response categorisation
Wider context from the report “(1) When the initial 999 call was placed by the deceased’s father at 22.05 on 28.10.20, it was accepted that he explicitly indicated to the Call Handler that the deceased had taken an overdose of, inter alia, ████████ tablets. Based upon that, & answers to other questions posed by the call handler, the call handler selected a protocol which did not appear to require this crucial piece of information to be either recorded within it, or to form part of the material which led to the categorisation of the call for the purposes of determining the appropriate response. In short, it led to a categorisation which could only loosely provide a response (based upon the level of demand that evening) estimate of around 3 hours . The concern here is that treatment for a massive ████████ overdose is time critical, & the processing of the call did not appear to accurately reflect the peril the deceased was then in, nor the importance of providing an acute emergency response .
” Source location Sarah Marie GILBERT-JONES · 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 Use Clinical Support Desk flags to identify overdose incidents and enable faster or out-of-order vehicle allocation.
Verbatim wording from the response “During the incident that was subject of the inquest, the floorwalker did upgrade the call to elicit a faster response, from an Amber 2 to an Amber 1. I wish to assure you that within the Standard Operating Procedure for the Clinical Support Desk, which allows clinicians to place a “flag” on an incident.” Source location 2022-0037-Response-from-Welsh-Ambulance-Services-NHS-Trust_Published
Open published response
19 Nov 2021 Robert Ellery · Prevention of Future Deaths report South Wales Central
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Concerns raised 2
Failure of the prison control room to provide specific information to the ambulance service when an ambulance is required View source Lack of a direct communication method between ambulance service call centre staff and prison staff providing basic life support 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. 2
Cardiff Prison
Devise a Local Operating Protocol governing direct communication between prison staff providing basic life support and the Welsh Ambulance Service.
View source
Cardiff Prison
Pilot mobile phones carried by the Orderly Officer and Night Orderly Officer to enable direct communication with the Welsh Ambulance Service during emergencies.
View source
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AI-generated summary
Robert Ellery · 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 Ellery was found ████████ in his prison cell on 31 October 2016. The report identified a 19-minute delay in informing the ambulance service and no direct communication method between ambulance call-centre staff and the prison staff providing basic life support. These issues delayed information sharing and impeded the provision of resuscitation guidance, giving rise to concerns about risks to other deaths.
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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 prison control room to provide specific information to the ambulance service when an ambulance is required
Wider context from the report “(1) The prison control room was not able to provide the Welsh Ambulance Service with any specific information as to the reason why an ambulance was required for 19 minutes after Mr Ellery was found ████████ in his cell. This delayed the ability of the ambulance service to despatch a response . While this was not, on the evidence heard by the jury, causative of Mr Ellery’s death, it gives rise to a concern that a risk that other deaths will occur.
” Source location Robert Ellery · 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 a direct communication method between ambulance service call centre staff and prison staff providing basic life support
Wider context from the report “(2) There was no method of communication to allow the Ambulance Service call centre staff to communicate directly with the nurse and officers who were providing basic life support to Mr Ellery. This delayed the relaying of specific information with respect to Mr Ellery’s condition by the prison to the Welsh Ambulance Service . It also impeded the ability of the ambulance service operator to provide guidance to those attempting to resuscitate Mr Ellery . This may affect the use of a defibrillator. In circumstances where not all prison staff are trained in the provision of CPR, it might also prevent the ambulance service operator providing instruction to first responders, or reduce the effectiveness of the same .
” Source location Robert Ellery · 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 Devise a Local Operating Protocol governing direct communication between prison staff providing basic life support and the Welsh Ambulance Service.
Verbatim wording from the response “At a local level, in recognition of the concerns raised by yourself, a Local Operating Protocol has been devised. HMP Cardiff will pilot the use of a mobile phone carried by the Orderly Officer and Night Orderly Officer to enable direct communication with the Welsh Ambulance Service. This will ensure updates from the scene can be provided directly to allow the Ambulance Service call centre staff to communicate directly with the nurse and officer providing basic life support to a patient. Our Local Operating Protocol sets out the following operational objectives:” Source location 2021-0390-Response-from-HMP-Cardiff_Published
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 Pilot mobile phones carried by the Orderly Officer and Night Orderly Officer to enable direct communication with the Welsh Ambulance Service during emergencies.
Verbatim wording from the response “At a local level, in recognition of the concerns raised by yourself, a Local Operating Protocol has been devised. HMP Cardiff will pilot the use of a mobile phone carried by the Orderly Officer and Night Orderly Officer to enable direct communication with the Welsh Ambulance Service. This will ensure updates from the scene can be provided directly to allow the Ambulance Service call centre staff to communicate directly with the nurse and officer providing basic life support to a patient. Our Local Operating Protocol sets out the following operational objectives:” Source location 2021-0390-Response-from-HMP-Cardiff_Published
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.